Provider Demographics
NPI:1043455181
Name:SANTIAM MEMORIAL HOSPITAL ER GROUP
Entity Type:Organization
Organization Name:SANTIAM MEMORIAL HOSPITAL ER GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETCHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-769-9233
Mailing Address - Street 1:1401 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1311
Mailing Address - Country:US
Mailing Address - Phone:503-769-2175
Mailing Address - Fax:503-769-5312
Practice Address - Street 1:1401 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1311
Practice Address - Country:US
Practice Address - Phone:503-769-2175
Practice Address - Fax:503-769-5312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0555102-0207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
380056Medicare PIN