Provider Demographics
NPI:1851616692
Name:BEND MEMORIAL CLINIC PC
Entity type:Organization
Organization Name:BEND MEMORIAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGFORS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-706-5401
Mailing Address - Street 1:1501 NE MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6051
Mailing Address - Country:US
Mailing Address - Phone:541-382-2811
Mailing Address - Fax:
Practice Address - Street 1:231 E CASCADE AVE
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759-1140
Practice Address - Country:US
Practice Address - Phone:541-549-0303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213243Medicaid
OR213243Medicaid