Provider Demographics
NPI:1942318613
Name:WILLAMETTE VALLEY RADIOLOGY
Entity Type:Organization
Organization Name:WILLAMETTE VALLEY RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:RT(R)
Authorized Official - Phone:503-362-0254
Mailing Address - Street 1:PO BOX 522
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97308-0522
Mailing Address - Country:US
Mailing Address - Phone:503-362-0254
Mailing Address - Fax:503-362-1082
Practice Address - Street 1:1155 MISSION ST SE
Practice Address - Street 2:SUITE 105
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6228
Practice Address - Country:US
Practice Address - Phone:503-362-0254
Practice Address - Fax:503-362-1082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022720Medicaid
OR022720Medicaid