Provider Demographics
NPI:1710114343
Name:ROGUE RIVER PALLIATIVE MEDICINE, LLC
Entity Type:Organization
Organization Name:ROGUE RIVER PALLIATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGUERITE
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-646-8575
Mailing Address - Street 1:1208 BEALL LN
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-1573
Mailing Address - Country:US
Mailing Address - Phone:541-664-5151
Mailing Address - Fax:541-664-5155
Practice Address - Street 1:979 WINDEMAR DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-9747
Practice Address - Country:US
Practice Address - Phone:541-646-8575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27812207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD27812OtherMEDICAL LICENSE NUMBER