Basic Information
| Provider Information | |||||||||
| NPI: | 1780846501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEND MEMORIAL CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 NE MEDICAL CENTER DR | ||||||||
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| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413822811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 NE NEFF RD | ||||||||
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| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413223504 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 01/31/2012 | ||||||||
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| AuthorizedOfficialLastName: | HAGFORS | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5417065401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 231243 | 05 | OR | MEDICAID |