Provider Demographics
NPI:1083762637
Name:WILD ROSE MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:WILD ROSE MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-686-4153
Mailing Address - Street 1:401 E 10TH AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3317
Mailing Address - Country:US
Mailing Address - Phone:541-686-4153
Mailing Address - Fax:541-686-3468
Practice Address - Street 1:401 E 10TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3317
Practice Address - Country:US
Practice Address - Phone:541-686-4153
Practice Address - Fax:541-686-3468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR072173Medicaid
ORP00193941Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE
ORC45172Medicare UPIN
ORR131120Medicare PIN