Basic Information
| Provider Information | |||||||||
| NPI: | 1952556490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOCRINOLOGY SERVICES NORTHWEST, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977090490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413302641 | ||||||||
| FaxNumber: | 5413883832 | ||||||||
| Practice Location | |||||||||
| Address1: | 2084 NE PROFESSIONAL CT | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413175600 | ||||||||
| FaxNumber: | 5413175676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2008 | ||||||||
| LastUpdateDate: | 11/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCCARTHY | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5418151409 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0902X | MD26567 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy | 207RE0101X | MD26567 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 131805 | 05 | OR | MEDICAID | 278317 | 05 | OR | MEDICAID |