Provider Demographics
NPI:1225217995
Name:MID VALLEY FAMILY PHYSICIANS
Entity Type:Organization
Organization Name:MID VALLEY FAMILY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:PALM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-393-0540
Mailing Address - Street 1:550 DIETZ AVE NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4615
Mailing Address - Country:US
Mailing Address - Phone:503-393-0540
Mailing Address - Fax:503-393-3695
Practice Address - Street 1:550 DIETZ AVE NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4615
Practice Address - Country:US
Practice Address - Phone:503-393-0540
Practice Address - Fax:503-393-3695
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID VALLEY FAMILY PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-30
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD025302207Q00000X
ORD025292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR232446Medicaid
ORG99921Medicare UPIN
OR232446Medicaid