Provider Demographics
NPI:1003946294
Name:BUCHANAN, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 BELLEVUE ST SE
Mailing Address - Street 2:SALEM HOSPITAL URGENT CARE CENTER
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 BELLEVUE ST SE
Practice Address - Street 2:SALEM HOSPITAL URGENT CARE CENTER
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4006
Practice Address - Country:US
Practice Address - Phone:503-561-5554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13298207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR116913Medicaid
E79827Medicare UPIN
OR116913Medicaid