Provider Demographics
NPI:1821293507
Name:PETER A HINCKLE
Entity Type:Organization
Organization Name:PETER A HINCKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:HINCKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-316-1970
Mailing Address - Street 1:600 NE AVALON PL
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-9258
Mailing Address - Country:US
Mailing Address - Phone:503-316-1970
Mailing Address - Fax:503-391-7422
Practice Address - Street 1:600 NE AVALON PL
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-9258
Practice Address - Country:US
Practice Address - Phone:503-316-1970
Practice Address - Fax:503-391-7422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18129174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR057443Medicaid
OR131618Medicare ID - Type Unspecified
ORA35687Medicare UPIN