Provider Demographics
NPI:1851622153
Name:ROSEBURG FOOT & ANKLE SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:ROSEBURG FOOT & ANKLE SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:FAE
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-673-7322
Mailing Address - Street 1:2300 NW STEWART PKWY
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1597
Mailing Address - Country:US
Mailing Address - Phone:541-673-7322
Mailing Address - Fax:541-673-3615
Practice Address - Street 1:2300 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-673-7322
Practice Address - Fax:541-673-3615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0586980-00OtherREGENCE BLUE CROSS
OR273OtherOREGON LICENSE NUMBER
OR500635904Medicaid
4307932-00OtherREGENCE MEDADVANTAGE
OR273OtherOREGON LICENSE NUMBER
ORU35623Medicare UPIN
ORDQ0864Medicare PIN
ORR152517Medicare PIN