Provider Demographics
NPI:1649244393
Name:BEND DERMATOLOGY CLINIC LLC
Entity Type:Organization
Organization Name:BEND DERMATOLOGY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAITLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-382-5712
Mailing Address - Street 1:2747 NE CONNERS AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-8738
Mailing Address - Country:US
Mailing Address - Phone:541-382-5712
Mailing Address - Fax:541-382-2605
Practice Address - Street 1:2747 NE CONNERS AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-8738
Practice Address - Country:US
Practice Address - Phone:541-382-5712
Practice Address - Fax:541-382-2605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286941Medicaid
ORR112783Medicare PIN