Provider Demographics
NPI:1730308529
Name:ROSEBURG HEART ASSOCIATES PC
Entity Type:Organization
Organization Name:ROSEBURG HEART ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:VAN DIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-677-6521
Mailing Address - Street 1:2700 NW STEWART PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1281
Mailing Address - Country:US
Mailing Address - Phone:541-677-6521
Mailing Address - Fax:
Practice Address - Street 1:2700 NW STEWART PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1281
Practice Address - Country:US
Practice Address - Phone:541-677-6521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12356207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR114985Medicare PIN