Provider Demographics
NPI:1164109906
Name:MCKENZIE RIVER GYNECOLOGY, LLC
Entity Type:Organization
Organization Name:MCKENZIE RIVER GYNECOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWNING-MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:CNM/NP
Authorized Official - Phone:541-505-1802
Mailing Address - Street 1:PO BOX 512
Mailing Address - Street 2:
Mailing Address - City:WALTERVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97489-0512
Mailing Address - Country:US
Mailing Address - Phone:541-505-1802
Mailing Address - Fax:541-314-9621
Practice Address - Street 1:1755 COBURG RD UNIT 503
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4900
Practice Address - Country:US
Practice Address - Phone:541-357-8307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-03
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1801865738Medicaid