Provider Demographics
NPI:1821366071
Name:CENTENNIAL MEDICAL GROUP EAST, LLC
Entity Type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP EAST, LLC
Other - Org Name:EVERGREEN FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-677-2494
Mailing Address - Street 1:2570 NW EDENBOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6214
Mailing Address - Country:US
Mailing Address - Phone:541-677-7200
Mailing Address - Fax:541-229-3309
Practice Address - Street 1:2570 NW EDENBOWER BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6214
Practice Address - Country:US
Practice Address - Phone:541-677-7200
Practice Address - Fax:541-229-3309
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTENNIAL MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-02
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR383880Medicare Oscar/Certification