Basic Information
| Provider Information | |||||||||
| NPI: | 1770671133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EBERLE | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1420 | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977560400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415266635 | ||||||||
| FaxNumber: | 5415266636 | ||||||||
| Practice Location | |||||||||
| Address1: | 213 NW LARCH AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977561323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415266635 | ||||||||
| FaxNumber: | 5415266636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 01/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD13613 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 12097978 | 01 | OR | CAQH ID | OTHER | 278645 | 05 | OR | MEDICAID |