Provider Demographics
NPI:1518103274
Name:CENTENNIAL MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:RAYLENE
Authorized Official - Last Name:VAN DIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-677-4319
Mailing Address - Street 1:201 NW MEDICAL LOOP STE 190
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8835
Mailing Address - Country:US
Mailing Address - Phone:541-644-4319
Mailing Address - Fax:541-677-2294
Practice Address - Street 1:201 NW MEDICAL LOOP STE 190
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8835
Practice Address - Country:US
Practice Address - Phone:541-644-4319
Practice Address - Fax:541-677-2294
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTENNIAL MEDICAL GROUP INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-31
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500601997Medicaid
ORR145783Medicare UPIN