Provider Demographics
NPI:1821274317
Name:SOUTHERN OREGON EAR NOSE & THROAT P C
Entity Type:Organization
Organization Name:SOUTHERN OREGON EAR NOSE & THROAT P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CINDI
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOUCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-734-3610
Mailing Address - Street 1:555 BLACK OAK DR STE 210
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8491
Mailing Address - Country:US
Mailing Address - Phone:541-734-3540
Mailing Address - Fax:
Practice Address - Street 1:555 BLACK OAK DR STE 210
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8491
Practice Address - Country:US
Practice Address - Phone:541-734-3540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17390207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR104911Medicare PIN