Provider Demographics
NPI: | 1851616692 |
---|---|
Name: | BEND MEMORIAL CLINIC PC |
Entity Type: | Organization |
Organization Name: | BEND MEMORIAL CLINIC PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | GREGORY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | HAGFORS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 541-706-5401 |
Mailing Address - Street 1: | 1501 NE MEDICAL CENTER DR |
Mailing Address - Street 2: | |
Mailing Address - City: | BEND |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97701-6051 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 541-382-2811 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 231 E CASCADE AVE |
Practice Address - Street 2: | |
Practice Address - City: | SISTERS |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97759-1140 |
Practice Address - Country: | US |
Practice Address - Phone: | 541-549-0303 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-04-05 |
Last Update Date: | 2012-01-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 213243 | Medicaid | |
OR | 213243 | Medicaid |