Provider Demographics
NPI:1871648402
Name:SOUTH SALEM IMMEDIATE CARE INC.
Entity Type:Organization
Organization Name:SOUTH SALEM IMMEDIATE CARE INC.
Other - Org Name:DBA URGENT CARE CLINIC SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-588-1234
Mailing Address - Street 1:3777 COMMERCIAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-588-1234
Mailing Address - Fax:503-371-8662
Practice Address - Street 1:3777 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-588-1234
Practice Address - Fax:503-371-8662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11684173000000X
207Q00000X, 207R00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130226Medicaid