Basic Information
| Provider Information | |||||||||
| NPI: | 1821035841 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS MEDICAL CENTER, P C | ||||||||
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| OtherOrganizationName: | PHYSICIANS MEDICAL CENTER, LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2435 NE CUMULUS AVE STE A | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971288862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034726161 | ||||||||
| FaxNumber: | 5034348498 | ||||||||
| Practice Location | |||||||||
| Address1: | 2435 NE CUMULUS AVE STE A | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971288862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034726161 | ||||||||
| FaxNumber: | 5034348498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRAIG | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5037584135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 38D0622888 | OR | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 38D0622888 | 01 | OR | CLIA# MEDICARE/MEDICAID | OTHER |