Provider Demographics
NPI:1316473176
Name:MIDDLEWAY MEDICINE
Entity type:Organization
Organization Name:MIDDLEWAY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:541-535-5082
Mailing Address - Street 1:PO BOX 960
Mailing Address - Street 2:88 LAPREE ST.
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-0960
Mailing Address - Country:US
Mailing Address - Phone:541-535-5082
Mailing Address - Fax:541-535-3026
Practice Address - Street 1:88 LAPREE ST
Practice Address - Street 2:
Practice Address - City:TALENT
Practice Address - State:OR
Practice Address - Zip Code:97540-6000
Practice Address - Country:US
Practice Address - Phone:541-535-5082
Practice Address - Fax:541-535-3026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00920171100000X
ORAC170159171100000X
ORAC00921171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500701484Medicaid
OR500705825Medicaid
OR500704629Medicaid