Basic Information
| Provider Information | |||||||||
| NPI: | 1194769299 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN OREGON ORTHOPAEDIC SURGERY & FRACTURE CLINIC INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EASTERN OREGON ORTHOPAEDIC SURGERY & SPORTS MEDICINE, LLP | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2714 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973392714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417585047 | ||||||||
| FaxNumber: | 5417583713 | ||||||||
| Practice Location | |||||||||
| Address1: | 3207 SW PERKINS AVE | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978013215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412764642 | ||||||||
| FaxNumber: | 5412764975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 11/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | CARVER | ||||||||
| AuthorizedOfficialFirstName: | BILLIE | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5417585047 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 157239-92 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.