Basic Information
| Provider Information | |||||||||
| NPI: | 1932227105 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN VIEW HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MOUNTAIN VIEW MEDICAL AND SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 470 NE A ST | ||||||||
| Address2: | |||||||||
| City: | MADRAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977411844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414753882 | ||||||||
| FaxNumber: | 5414750610 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 NE A ST | ||||||||
| Address2: | |||||||||
| City: | MADRAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977411844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414604001 | ||||||||
| FaxNumber: | 5414754804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 06/23/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEWLEY | ||||||||
| AuthorizedOfficialFirstName: | MARTHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5414604001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNTAIN VIEW HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 151024 | 05 | OR | MEDICAID |