Provider Demographics
NPI:1689915753
Name:EHRLICH, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:EHRLICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97458-1066
Mailing Address - Country:US
Mailing Address - Phone:541-572-2111
Mailing Address - Fax:541-572-5743
Practice Address - Street 1:324 4TH ST
Practice Address - Street 2:
Practice Address - City:MYRTLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97458-1066
Practice Address - Country:US
Practice Address - Phone:541-572-2111
Practice Address - Fax:541-572-5743
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORPA169670363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500677615Medicaid
OR1407812365OtherGROUP NPI NORTH BEND MEDICAL CENTER
OR161133OtherGROUP DMAP NORTH BEND MEDICAL CENTER
OR93-0635514OtherGROUP TAX ID NORTH BEND MEDICAL CENTER
ORR0000WFBTVOtherGROUP MEDICARE NORTH BEND MEDICAL CENTER
OR161133OtherGROUP DMAP NORTH BEND MEDICAL CENTER