Provider Demographics
NPI:1508921016
Name:BRUCE D. CARLSON M.D.
Entity Type:Organization
Organization Name:BRUCE D. CARLSON M.D.
Other - Org Name:HERMISTON FAMILY MEDICINE AND URGENT CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-567-1137
Mailing Address - Street 1:236 E NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-2449
Mailing Address - Country:US
Mailing Address - Phone:541-567-1137
Mailing Address - Fax:541-567-2336
Practice Address - Street 1:236 E NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2449
Practice Address - Country:US
Practice Address - Phone:541-567-1137
Practice Address - Fax:541-567-2336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR223149Medicaid
OROR1807OtherHEALTH NET OF OREGON
OR080385000OtherBLUE CROSS BLUE SHIELD
OR38-3858Medicare Oscar/Certification
OROR1807OtherHEALTH NET OF OREGON