Basic Information
| Provider Information | |||||||||
| NPI: | 1689266926 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | P3 MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2370 CORPORATE CIR STE 300 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890747760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027802425 | ||||||||
| FaxNumber: | 7027866650 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 12TH ST SE STE 260 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9717013058 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2021 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7029148237 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.