Provider Demographics
NPI:1316122708
Name:GERALD ENGSTROM
Entity type:Organization
Organization Name:GERALD ENGSTROM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ENGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-673-3447
Mailing Address - Street 1:1813 W HARVARD AVE STE 427
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-8712
Mailing Address - Country:US
Mailing Address - Phone:541-673-3447
Mailing Address - Fax:541-677-9712
Practice Address - Street 1:1813 W HARVARD AVE STE 427
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-8712
Practice Address - Country:US
Practice Address - Phone:541-673-3447
Practice Address - Fax:541-677-9712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15315207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151282Medicaid
ORR111595Medicare PIN