Provider Demographics
NPI:1598868515
Name:INDEPENDENCE-MONMOUTH FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:INDEPENDENCE-MONMOUTH FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICIAL REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-838-1133
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97351
Mailing Address - Country:US
Mailing Address - Phone:503-838-1133
Mailing Address - Fax:503-838-5138
Practice Address - Street 1:1430 MONMOUTH ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OR
Practice Address - Zip Code:97351
Practice Address - Country:US
Practice Address - Phone:503-838-1133
Practice Address - Fax:503-838-5138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269340Medicaid
R134073Medicare PIN
OR269340Medicaid