Provider Demographics
NPI:1659442960
Name:EUGENE PEDIATRIC ASSOCIATES LLC
Entity Type:Organization
Organization Name:EUGENE PEDIATRIC ASSOCIATES LLC
Other - Org Name:EUGENE PEDIATRIC ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-484-5443
Mailing Address - Street 1:995 WILLAGILLESPIE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2186
Mailing Address - Country:US
Mailing Address - Phone:541-484-5443
Mailing Address - Fax:541-687-5621
Practice Address - Street 1:995 WILLAGILLESPIE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2186
Practice Address - Country:US
Practice Address - Phone:541-484-5443
Practice Address - Fax:541-687-5621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD095832080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE40853Medicare UPIN