Provider Demographics
NPI:1518171339
Name:INTERNAL MEDICINE & GERIATRICS, P.C.
Entity Type:Organization
Organization Name:INTERNAL MEDICINE & GERIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:RANGANATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJENDRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-677-8900
Mailing Address - Street 1:3369 NE STEPHENS ST.
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470
Mailing Address - Country:US
Mailing Address - Phone:541-677-8900
Mailing Address - Fax:541-677-8903
Practice Address - Street 1:3369 NE STEPHENS ST.
Practice Address - Street 2:STE. 100
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470
Practice Address - Country:US
Practice Address - Phone:541-677-8900
Practice Address - Fax:541-677-8900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24877174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029057Medicaid
OR=========OtherTAX ID
OR029057Medicaid