Provider Demographics
NPI:1699103598
Name:CENTENNIAL MEDICAL GROUP EAST, LLC
Entity type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP EAST, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:TYREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-229-3332
Mailing Address - Street 1:2801 NW MERCY DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2348
Mailing Address - Country:US
Mailing Address - Phone:541-677-2494
Mailing Address - Fax:541-677-2294
Practice Address - Street 1:145 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MYRTLE CREEK
Practice Address - State:OR
Practice Address - Zip Code:97457-9039
Practice Address - Country:US
Practice Address - Phone:541-863-3146
Practice Address - Fax:541-863-3226
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTENNIAL MEDICAL GROUP DBA EVERGREEN FAMILY MEDICINE SOUTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-31
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR71216890207Q00000X
OR207Q00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR383891Medicare Oscar/Certification