Provider Demographics
NPI:1033365135
Name:CENTENNIAL MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP INC.
Other - Org Name:CENTENNIAL SHAW HEART & VASCULAR SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ARIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSHONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-677-4319
Mailing Address - Street 1:201 NW MEDICAL LOOP STE 190
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8835
Mailing Address - Country:US
Mailing Address - Phone:541-677-4319
Mailing Address - Fax:541-677-2294
Practice Address - Street 1:2801 NW MERCY DR STE 300
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2348
Practice Address - Country:US
Practice Address - Phone:541-677-1555
Practice Address - Fax:541-677-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RC0000X, 207RI0011X, 2085R0204X
OR141133207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000ZGBFMOtherMEDICARE PART B