Provider Demographics
NPI:1164436085
Name:REDMOND INTERNAL MEDICINE CLINIC,LLP
Entity Type:Organization
Organization Name:REDMOND INTERNAL MEDICINE CLINIC,LLP
Other - Org Name:REDMOND MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORELEI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:541-323-4540
Mailing Address - Street 1:1245 NW 4TH STREET
Mailing Address - Street 2:STE 201
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1680
Mailing Address - Country:US
Mailing Address - Phone:541-323-4545
Mailing Address - Fax:541-323-4546
Practice Address - Street 1:1245 NW 4TH STREET
Practice Address - Street 2:STE 201
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1680
Practice Address - Country:US
Practice Address - Phone:541-323-4545
Practice Address - Fax:541-323-4546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19294/MD23086174400000X
207R00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287491Medicaid
OR72376Medicaid
ORG09287Medicare UPIN
ORR114525Medicare ID - Type Unspecified
ORG08451Medicare UPIN
OR287491Medicaid