Provider Demographics
NPI:1437302452
Name:DERMATOLOGY CLINIC OF SPRINGFIELD
Entity Type:Organization
Organization Name:DERMATOLOGY CLINIC OF SPRINGFIELD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:K
Authorized Official - Last Name:RICHEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-747-6159
Mailing Address - Street 1:1605 G STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4227
Mailing Address - Country:US
Mailing Address - Phone:541-747-6159
Mailing Address - Fax:541-741-7249
Practice Address - Street 1:1605 G STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4227
Practice Address - Country:US
Practice Address - Phone:541-747-6159
Practice Address - Fax:541-741-7249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR114095Medicare PIN