Provider Demographics
NPI:1346227402
Name:TILLAMOOK MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:TILLAMOOK MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SID
Authorized Official - Middle Name:
Authorized Official - Last Name:RITTENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-842-5546
Mailing Address - Street 1:980 3RD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-9469
Mailing Address - Country:US
Mailing Address - Phone:503-842-5546
Mailing Address - Fax:503-842-1444
Practice Address - Street 1:980 3RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-9469
Practice Address - Country:US
Practice Address - Phone:503-842-5546
Practice Address - Fax:503-842-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR117023Medicaid
OR0000WCGNDMedicare ID - Type Unspecified
OR383823Medicare Oscar/Certification