Provider Demographics
NPI:1033270863
Name:DOUGLAS MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:DOUGLAS MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-440-6390
Mailing Address - Street 1:1813 W HARVARD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-2752
Mailing Address - Country:US
Mailing Address - Phone:541-440-6390
Mailing Address - Fax:541-440-6392
Practice Address - Street 1:1813 W HARVARD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2752
Practice Address - Country:US
Practice Address - Phone:541-440-6390
Practice Address - Fax:541-440-6392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288040Medicaid
ORR111530Medicare ID - Type Unspecified