Provider Demographics
NPI:1063454395
Name:SALEM EMERGENCY PHYSICIANS SERVICE, PC
Entity Type:Organization
Organization Name:SALEM EMERGENCY PHYSICIANS SERVICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-561-5634
Mailing Address - Street 1:PO BOX 742547
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2547
Mailing Address - Country:US
Mailing Address - Phone:503-561-5634
Mailing Address - Fax:503-814-1071
Practice Address - Street 1:890 OAK STREET
Practice Address - Street 2:SE BUILDING 'A'
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3905
Practice Address - Country:US
Practice Address - Phone:503-561-5634
Practice Address - Fax:503-814-1071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
015388000OtherBLUE CROSS & BLUE SHIELD
042080OtherWASHINGTON L&I
OR115808Medicaid
WA7028699Medicaid
OR168143Medicaid
CR0251OtherRAILROAD MEDICARE
68701001OtherGROUP HEALTH
8902424OtherWASHINGTON CRIME VICTIMS
OR115808Medicaid