Basic Information
| Provider Information | |||||||||
| NPI: | 1710114343 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROGUE RIVER PALLIATIVE MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1208 BEALL LN | ||||||||
| Address2: | |||||||||
| City: | CENTRAL POINT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975021573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416645151 | ||||||||
| FaxNumber: | 5416645155 | ||||||||
| Practice Location | |||||||||
| Address1: | 979 WINDEMAR DR | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975209747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416468575 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2009 | ||||||||
| LastUpdateDate: | 09/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | WILKINS | ||||||||
| AuthorizedOfficialFirstName: | MARGUERITE | ||||||||
| AuthorizedOfficialMiddleName: | DAVIS | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5416468575 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD27812 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD27812 | 01 | OR | MEDICAL LICENSE NUMBER | OTHER |