Provider Demographics
NPI:1124352877
Name:WVP MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:WVP MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-371-7701
Mailing Address - Street 1:2995 RYAN DR SE
Mailing Address - Street 2:STE. 200
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-5157
Mailing Address - Country:US
Mailing Address - Phone:503-371-7701
Mailing Address - Fax:
Practice Address - Street 1:2485 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2151
Practice Address - Country:US
Practice Address - Phone:503-363-8047
Practice Address - Fax:503-363-6571
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID VALLEY IPA INC. (WVP HEALTH AUTHORITY)
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-29
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR151720OtherPTAN
OR288533Medicaid