Provider Demographics
NPI:1124215736
Name:BANDON FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:BANDON FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-329-1362
Mailing Address - Street 1:475 ELMIRA AVE SE STE 201
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-7409
Mailing Address - Country:US
Mailing Address - Phone:541-329-1362
Mailing Address - Fax:541-329-1364
Practice Address - Street 1:475 ELMIRA AVE SE STE 201
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-7409
Practice Address - Country:US
Practice Address - Phone:541-329-1362
Practice Address - Fax:541-329-1364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR244093Medicaid
OR244093Medicaid
ORR139080Medicare PIN