Basic Information
| Provider Information | |||||||||
| NPI: | 1548373137 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SILVERTON HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3417 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038731500 | ||||||||
| FaxNumber: | 5038731534 | ||||||||
| Practice Location | |||||||||
| Address1: | 347 FAIRVIEW ST | ||||||||
| Address2: | |||||||||
| City: | SILVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973811916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038735667 | ||||||||
| FaxNumber: | 5038735687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 12/01/2017 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM CFO | ||||||||
| AuthorizedOfficialTelephone: | 5034155145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SILVERTON HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 213087 | 05 | OR | MEDICAID | R0000WCLBP | 01 | OR | MEDICARE PART B | OTHER |