Provider Demographics
NPI:1134136013
Name:KIDSDOCS PC
Entity Type:Organization
Organization Name:KIDSDOCS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:OUTCALT
Authorized Official - Last Name:GROSHONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-957-5437
Mailing Address - Street 1:201 NW MEDICAL LOOP
Mailing Address - Street 2:#170
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8821
Mailing Address - Country:US
Mailing Address - Phone:541-957-5437
Mailing Address - Fax:541-464-5441
Practice Address - Street 1:201 NW MEDICAL LOOP
Practice Address - Street 2:#170
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8821
Practice Address - Country:US
Practice Address - Phone:541-957-5437
Practice Address - Fax:541-464-5441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005908Medicaid