Provider Demographics
NPI:1861674780
Name:MARK ALLEN RONDEAU
Entity Type:Organization
Organization Name:MARK ALLEN RONDEAU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:MELONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DECHENNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-476-8859
Mailing Address - Street 1:124 NW MIDLAND AVE
Mailing Address - Street 2:STE J
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1269
Mailing Address - Country:US
Mailing Address - Phone:541-476-8859
Mailing Address - Fax:541-955-8611
Practice Address - Street 1:124 NW MIDLAND AVE
Practice Address - Street 2:STE J
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1269
Practice Address - Country:US
Practice Address - Phone:541-476-8859
Practice Address - Fax:541-955-8611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288514Medicaid
ORH15389Medicare UPIN