Basic Information
| Provider Information | |||||||||
| NPI: | 1790937142 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLAMETTE COMMUNITY MEDICAL GROUP LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADULT MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7100 COMMERCE WAY | ||||||||
| Address2: | STE 180 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370272829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657000 | ||||||||
| FaxNumber: | 6154653017 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 COUNTRY CLUB RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974016024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413422134 | ||||||||
| FaxNumber: | 5416866021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2008 | ||||||||
| LastUpdateDate: | 02/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6154657631 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WILLAMETTE COMMUNITY MEDICAL GROUP LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1790937142 | 01 | OR | NPI | OTHER |