Provider Demographics
NPI:1508815754
Name:BEND UROLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:BEND UROLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-382-6447
Mailing Address - Street 1:2090 NE WYATT CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7687
Mailing Address - Country:US
Mailing Address - Phone:541-382-6447
Mailing Address - Fax:541-330-7413
Practice Address - Street 1:2090 NE WYATT CT
Practice Address - Street 2:SUITE 101
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7687
Practice Address - Country:US
Practice Address - Phone:541-382-6447
Practice Address - Fax:541-330-7413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101364Medicare ID - Type UnspecifiedRDMD
OR101348Medicare ID - Type Unspecified