Provider Demographics
NPI:1114190121
Name:ROGUE VALLEY PHYSICIANS PC
Entity Type:Organization
Organization Name:ROGUE VALLEY PHYSICIANS PC
Other - Org Name:FAMILY PRACTICE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-282-8817
Mailing Address - Street 1:2900 DOCTORS PARK DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8198
Mailing Address - Country:US
Mailing Address - Phone:541-282-2208
Mailing Address - Fax:
Practice Address - Street 1:229 W STEWART AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3663
Practice Address - Country:US
Practice Address - Phone:541-282-8808
Practice Address - Fax:541-681-6452
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROGUE VALLEY PHYSICIANS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-10
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218621Medicaid
ORR105049Medicare PIN