Basic Information
| Provider Information | |||||||||
| NPI: | 1649244393 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEND DERMATOLOGY CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2747 NE CONNERS AVE | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977018738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413825712 | ||||||||
| FaxNumber: | 5413822605 | ||||||||
| Practice Location | |||||||||
| Address1: | 2747 NE CONNERS AVE | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977018738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413825712 | ||||||||
| FaxNumber: | 5413822605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 06/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | MAITLAND | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5413825712 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 286941 | 05 | OR | MEDICAID |