Provider Demographics
NPI:1538459938
Name:WVP MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:WVP MEDICAL GROUP, LLC
Other - Org Name:WVP-MCGILCHRIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-371-7701
Mailing Address - Street 1:2478 13TH ST SE
Mailing Address - Street 2:STE. 200
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2546
Mailing Address - Country:US
Mailing Address - Phone:503-588-5892
Mailing Address - Fax:503-485-0709
Practice Address - Street 1:2478 13TH ST SE
Practice Address - Street 2:STE. 200
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2546
Practice Address - Country:US
Practice Address - Phone:503-588-5892
Practice Address - Fax:505-485-0709
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID VALLEY IPA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-19
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care