Provider Demographics
NPI:1750684767
Name:WVP MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:WVP MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-371-7701
Mailing Address - Street 1:2995 RYAN DR SE STE 200
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-5157
Mailing Address - Country:US
Mailing Address - Phone:503-371-7701
Mailing Address - Fax:
Practice Address - Street 1:5100 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-5371
Practice Address - Country:US
Practice Address - Phone:503-393-2533
Practice Address - Fax:503-393-5978
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID VALLEY IPA (WVP HEALTH AUTHORITY)
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-13
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288533Medicaid