Provider Demographics
NPI:1770669467
Name:ROGUE VALLEY FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:ROGUE VALLEY FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARY
Authorized Official - Middle Name:PARKER
Authorized Official - Last Name:STIEGLITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-608-3764
Mailing Address - Street 1:691 MURPHY RD
Mailing Address - Street 2:SUITE 224
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4346
Mailing Address - Country:US
Mailing Address - Phone:541-608-3764
Mailing Address - Fax:541-608-4796
Practice Address - Street 1:691 MURPHY RD
Practice Address - Street 2:SUITE 224
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4346
Practice Address - Country:US
Practice Address - Phone:541-608-3764
Practice Address - Fax:541-608-4796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR042929Medicaid
OR105752Medicare ID - Type Unspecified
ORE79065Medicare UPIN