Provider Demographics
NPI:1043398159
Name:EDGAR MAEYENS JR MD PC
Entity Type:Organization
Organization Name:EDGAR MAEYENS JR MD PC
Other - Org Name:PARK AVENUE DERMATOLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MAEYENS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:541-267-7543
Mailing Address - Street 1:375 PARK AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2244
Mailing Address - Country:US
Mailing Address - Phone:541-267-7543
Mailing Address - Fax:541-267-2076
Practice Address - Street 1:375 PARK AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2244
Practice Address - Country:US
Practice Address - Phone:541-267-7543
Practice Address - Fax:541-267-2076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08528174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR009894000OtherBLUE CROSS ID #
OR009894000OtherBLUE CROSS ID #
ORC93204Medicare UPIN