Provider Demographics
NPI:1427056324
Name:COLUMBIA GORGE ENT, LLC
Entity type:Organization
Organization Name:COLUMBIA GORGE ENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-298-5563
Mailing Address - Street 1:1815 E 19TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3365
Mailing Address - Country:US
Mailing Address - Phone:541-298-5563
Mailing Address - Fax:541-298-7746
Practice Address - Street 1:1815 E 19TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3365
Practice Address - Country:US
Practice Address - Phone:541-298-5563
Practice Address - Fax:541-298-7746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10654207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022888Medicaid
WA7124860Medicaid
ORDB9629OtherRAILROAD MEDICARE
OR120373Medicare PIN
ORC92640Medicare UPIN