Provider Demographics
NPI:1568653285
Name:ROBERT M GENTRY
Entity type:Organization
Organization Name:ROBERT M GENTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-474-5511
Mailing Address - Street 1:1585 NW WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1049
Mailing Address - Country:US
Mailing Address - Phone:541-474-5511
Mailing Address - Fax:
Practice Address - Street 1:1585 NW WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1049
Practice Address - Country:US
Practice Address - Phone:541-474-5511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR043364Medicaid
ORR106200Medicare PIN