Provider Demographics
NPI:1043248917
Name:ROGUE ANESTHESIA LLC
Entity Type:Organization
Organization Name:ROGUE ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:541-472-4884
Mailing Address - Street 1:5319 SW WESTGATE DR
Mailing Address - Street 2:241
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2432
Mailing Address - Country:US
Mailing Address - Phone:503-297-7223
Mailing Address - Fax:503-297-7603
Practice Address - Street 1:1601 NW HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526
Practice Address - Country:US
Practice Address - Phone:541-472-4884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18872207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130351Medicaid
OR023807000OtherREGENCE BCBSO
OR130351Medicaid