Provider Demographics
NPI:1366449662
Name:MEDFORD MEDICAL CLINIC, LLP
Entity Type:Organization
Organization Name:MEDFORD MEDICAL CLINIC, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:KANE
Authorized Official - Last Name:VANVALKENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-734-3430
Mailing Address - Street 1:PO BOX 7841
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-7800
Mailing Address - Country:US
Mailing Address - Phone:541-734-3430
Mailing Address - Fax:541-734-3666
Practice Address - Street 1:555 BLACK OAK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8447
Practice Address - Country:US
Practice Address - Phone:541-734-3430
Practice Address - Fax:541-734-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21703207Q00000X
OR207Q00000X, 207R00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORG46004Medicare UPIN
OR4889450001Medicare NSC