Basic Information
| Provider Information | |||||||||
| NPI: | 1558358721 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEART CLINIC OF SOUTHERN OREGON & NORTHERN CALIFORNIA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 MEDICAL CENTER DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412826600 | ||||||||
| FaxNumber: | 5412826608 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412826600 | ||||||||
| FaxNumber: | 5412826608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | DAILEY | ||||||||
| AuthorizedOfficialFirstName: | REGAN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5412826620 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 130327 | 05 | OR | MEDICAID | CG2868 | 01 | OR | RAILROAD MEDICARE | OTHER |