Provider Demographics
NPI:1568465805
Name:PARAGON ORTHOPEDIC CENTER, PC
Entity Type:Organization
Organization Name:PARAGON ORTHOPEDIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELONY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-472-0603
Mailing Address - Street 1:702 SW RAMSEY AVE
Mailing Address - Street 2:STE 112
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5858
Mailing Address - Country:US
Mailing Address - Phone:541-472-0603
Mailing Address - Fax:541-472-0609
Practice Address - Street 1:702 RAMSEY AVE
Practice Address - Street 2:STE 112
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5573
Practice Address - Country:US
Practice Address - Phone:541-472-0603
Practice Address - Fax:541-472-0609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1148312-9207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCJ7205OtherMEDICARE RAILROAD
OR286970Medicaid
OR286970Medicaid