Provider Demographics
NPI:1255302444
Name:JANNELLI, CHRIS ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:ANTHONY
Last Name:JANNELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 NW STEWART PKWY
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1281
Mailing Address - Country:US
Mailing Address - Phone:541-677-4313
Mailing Address - Fax:541-677-4533
Practice Address - Street 1:2700 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1281
Practice Address - Country:US
Practice Address - Phone:541-677-4313
Practice Address - Fax:541-677-4533
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2009-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15609207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8363459Medicaid
OR078386Medicaid
OR930069801OtherRAILROAD MEDICRE
OR101670Medicare ID - Type Unspecified
WA8363459Medicaid
OR078386Medicaid
ORR145111Medicare PIN