Provider Demographics
NPI:1891178885
Name:SNAKE RIVER PEDIATRICS
Entity Type:Organization
Organization Name:SNAKE RIVER PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:AMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-881-2380
Mailing Address - Street 1:1050 SW 3RD AVE STE 3200
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-4560
Mailing Address - Country:US
Mailing Address - Phone:541-881-2380
Mailing Address - Fax:541-881-2389
Practice Address - Street 1:1050 SW 3RD AVE STE 3200
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-4560
Practice Address - Country:US
Practice Address - Phone:541-881-2380
Practice Address - Fax:541-881-2389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA000573208000000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1982791810OtherNPI
OR500608077Medicaid