Basic Information
| Provider Information | |||||||||
| NPI: | 1598954562 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CURRY HEALTH DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CURRY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 500 5TH STREET | ||||||||
| Address2: | |||||||||
| City: | BROOKINGS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414122000 | ||||||||
| FaxNumber: | 5414122070 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 5TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKINGS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974159702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414122000 | ||||||||
| FaxNumber: | 5414122070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLCUTT | ||||||||
| AuthorizedOfficialFirstName: | SHELLIE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5414122073 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD181844 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 213089 | 05 | OR | MEDICAID |