Provider Demographics
NPI:1376608901
Name:BRUCE D. CARLSON
Entity Type:Organization
Organization Name:BRUCE D. CARLSON
Other - Org Name:GILLIAM COUNTY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-384-2061
Mailing Address - Street 1:PO BOX 705
Mailing Address - Street 2:
Mailing Address - City:CONDON
Mailing Address - State:OR
Mailing Address - Zip Code:97823-0705
Mailing Address - Country:US
Mailing Address - Phone:541-384-2061
Mailing Address - Fax:
Practice Address - Street 1:422 N MAIN
Practice Address - Street 2:
Practice Address - City:CONDON
Practice Address - State:OR
Practice Address - Zip Code:97823-0705
Practice Address - Country:US
Practice Address - Phone:541-384-2061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR223149Medicaid
DA2998OtherMEDICARE-RAILROAD
R108416Medicare PIN