Provider Demographics
NPI:1477613529
Name:ROGUE RIVER FAMILY PRACTICE CLINIC PC
Entity Type:Organization
Organization Name:ROGUE RIVER FAMILY PRACTICE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:H
Authorized Official - Last Name:GLOVINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-582-0505
Mailing Address - Street 1:PO BOX 1020
Mailing Address - Street 2:
Mailing Address - City:ROGUE RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97537-9674
Mailing Address - Country:US
Mailing Address - Phone:541-582-0505
Mailing Address - Fax:541-582-0778
Practice Address - Street 1:509 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:ROGUE RIVER
Practice Address - State:OR
Practice Address - Zip Code:97537-9674
Practice Address - Country:US
Practice Address - Phone:541-582-0505
Practice Address - Fax:541-582-0778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR113597Medicaid
OR113597Medicaid