Provider Demographics
NPI:1568434025
Name:EVERGREEN FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:EVERGREEN FAMILY MEDICINE, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:TYREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-229-3332
Mailing Address - Street 1:2570 NW EDENBOWER BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6214
Mailing Address - Country:US
Mailing Address - Phone:541-677-7200
Mailing Address - Fax:541-677-3309
Practice Address - Street 1:1937 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2720
Practice Address - Country:US
Practice Address - Phone:541-677-7200
Practice Address - Fax:541-229-3309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORJ8799-01OtherGROUP PACIFIC SOURCE
OR213560Medicaid
OR610550200OtherGROUP OWCP
OR845023000OtherGROUP BLUE CROSS
OR610550200OtherGROUP OWCP