Provider Demographics
NPI:1083745038
Name:TWO RIVERS CLINIC
Entity Type:Organization
Organization Name:TWO RIVERS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-484-4339
Mailing Address - Street 1:1941 POTTER STREET
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3059
Mailing Address - Country:US
Mailing Address - Phone:541-485-9534
Mailing Address - Fax:
Practice Address - Street 1:995 WILLAGILLESPIE, STE 200A
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-484-4339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR027565Medicaid
ORA49953Medicare UPIN
OR027565Medicaid