Provider Demographics
NPI:1407897895
Name:THURSTON MEDICAL CLINIC
Entity Type:Organization
Organization Name:THURSTON MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SEC/TREAS
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:GEISLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-746-1166
Mailing Address - Street 1:147 S 52ND PLACE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-6210
Mailing Address - Country:US
Mailing Address - Phone:541-393-1601
Mailing Address - Fax:541-393-1603
Practice Address - Street 1:147 S 52ND PLACE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-6210
Practice Address - Country:US
Practice Address - Phone:541-393-1601
Practice Address - Fax:541-393-1603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
38D0627525Medicare UPIN
OOWFBLYAMedicare ID - Type Unspecified