Provider Demographics
NPI:1033444781
Name:SOUTHERN OREGON CARDIOLOGY LLC
Entity Type:Organization
Organization Name:SOUTHERN OREGON CARDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BODAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-789-5600
Mailing Address - Street 1:520 MEDICAL CENTER DR
Mailing Address - Street 2:STE 200
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4314
Mailing Address - Country:US
Mailing Address - Phone:541-282-6600
Mailing Address - Fax:541-282-6601
Practice Address - Street 1:520 MEDICAL CENTER DR
Practice Address - Street 2:STE 200
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4314
Practice Address - Country:US
Practice Address - Phone:541-282-6600
Practice Address - Fax:541-282-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-14
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1000026501207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR150509Medicare PIN