Basic Information
| Provider Information | |||||||||
| NPI: | 1568556934 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DALLAS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANGELA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1420 | ||||||||
| Address2: | ST. CHARLES MEDICAL GROUP | ||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977560400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415266556 | ||||||||
| FaxNumber: | 5417063765 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 NE NEFF RD | ||||||||
| Address2: | ST. CHARLES MEDICAL GROUP | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415266556 | ||||||||
| FaxNumber: | 5417063765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 01/12/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD153008 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 93286 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8785 | 05 | NM | MEDICAID |