Provider Demographics
NPI:1598930430
Name:WILD RIVERS PHYSIATRY, INC
Entity Type:Organization
Organization Name:WILD RIVERS PHYSIATRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:COELHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-464-7840
Mailing Address - Street 1:PO BOX 950
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-0950
Mailing Address - Country:US
Mailing Address - Phone:707-464-7840
Mailing Address - Fax:707-464-7845
Practice Address - Street 1:585 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9702
Practice Address - Country:US
Practice Address - Phone:707-464-7840
Practice Address - Fax:707-464-7845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26085174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273955Medicaid
ORRHD146992OtherRADIOGRAPHY AND FLUOROSCOPY
ORRHD146992OtherRADIOGRAPHY AND FLUOROSCOPY
ORH00384Medicare UPIN