Provider Demographics
NPI:1891003497
Name:CENTENNIAL MEDICAL GROUP WEST, LLC
Entity Type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP WEST, LLC
Other - Org Name:GERALD ENGSTROM, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAHUL
Authorized Official - Middle Name:
Authorized Official - Last Name:AGARWAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-677-2494
Mailing Address - Street 1:2801 NW MERCY DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2348
Mailing Address - Country:US
Mailing Address - Phone:541-677-2494
Mailing Address - Fax:541-677-2294
Practice Address - Street 1:2801 NW MERCY DR
Practice Address - Street 2:SUITE 345
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2348
Practice Address - Country:US
Practice Address - Phone:541-677-2494
Practice Address - Fax:541-677-2294
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTENNIAL MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15315207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty