Provider Demographics
NPI:1760418032
Name:GRANTS PASS CLINIC LLP
Entity Type:Organization
Organization Name:GRANTS PASS CLINIC LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:GASSAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-472-5500
Mailing Address - Street 1:495 SW RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5681
Mailing Address - Country:US
Mailing Address - Phone:541-472-5580
Mailing Address - Fax:541-472-5673
Practice Address - Street 1:495 RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5681
Practice Address - Country:US
Practice Address - Phone:541-476-6644
Practice Address - Fax:541-472-5673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 207RI0200X, 208000000X, 208600000X, 213E00000X
OR332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1268610001Medicare NSC
0000WCGBMMedicare ID - Type Unspecified