Provider Demographics
NPI:1417929050
Name:EVERGREEN FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:EVERGREEN FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-229-3301
Mailing Address - Street 1:2570 NW EDENBOWER BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-6214
Mailing Address - Country:US
Mailing Address - Phone:541-229-3301
Mailing Address - Fax:541-677-7462
Practice Address - Street 1:2570 NW EDENBOWER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6214
Practice Address - Country:US
Practice Address - Phone:541-229-3301
Practice Address - Fax:541-677-7462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000116Medicaid
ORCN5472OtherGROUP RAILROAD
OR000116Medicaid