Provider Demographics
NPI:1871665901
Name:TIMBER VALLEY MEDICAL CLINIC P C
Entity Type:Organization
Organization Name:TIMBER VALLEY MEDICAL CLINIC P C
Other - Org Name:TIMBER VALLEY FAMILY CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CORPORATION PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:541-741-1226
Mailing Address - Street 1:21 HAYDEN BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1305
Mailing Address - Country:US
Mailing Address - Phone:541-741-1226
Mailing Address - Fax:541-714-0673
Practice Address - Street 1:21 HAYDEN BRIDGE WAY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1305
Practice Address - Country:US
Practice Address - Phone:541-741-1226
Practice Address - Fax:541-714-0673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO 08511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCJ9204OtherRAILROAD MEDICARE
OR240511Medicaid
ORCJ9204OtherRAILROAD MEDICARE
OR=========97477A001OtherTRICARE
ORCJ9204OtherRAILROAD MEDICARE