Provider Demographics
NPI:1629174495
Name:APPLEGATE VALLEY FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:APPLEGATE VALLEY FAMILY MEDICINE, LLC
Other - Org Name:APPLEGATE VALLEY FAMILY MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOGG
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:541-862-2836
Mailing Address - Street 1:8600 NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-8978
Mailing Address - Country:US
Mailing Address - Phone:541-862-2836
Mailing Address - Fax:541-862-2806
Practice Address - Street 1:8600 NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-8978
Practice Address - Country:US
Practice Address - Phone:541-862-2836
Practice Address - Fax:541-862-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR222705-99363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
R119633Medicare ID - Type Unspecified