Provider Demographics
NPI:1992149322
Name:SANTIAM MEDICAL GROUP LLC
Entity type:Organization
Organization Name:SANTIAM MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:
Authorized Official - First Name:MAGGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-769-9236
Mailing Address - Street 1:1401 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1311
Mailing Address - Country:US
Mailing Address - Phone:503-769-2175
Mailing Address - Fax:503-769-5877
Practice Address - Street 1:1401 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1311
Practice Address - Country:US
Practice Address - Phone:503-769-2175
Practice Address - Fax:503-769-5877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center