Provider Demographics
NPI:1740668649
Name:CORVALLIS MEDICAL GROUP LLC
Entity type:Organization
Organization Name:CORVALLIS MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:BULL
Authorized Official - Last Name:RASK
Authorized Official - Suffix:
Authorized Official - Credentials:PE
Authorized Official - Phone:541-368-3032
Mailing Address - Street 1:800 NE CIRCLE BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4256
Mailing Address - Country:US
Mailing Address - Phone:541-286-4742
Mailing Address - Fax:833-450-5933
Practice Address - Street 1:800 NE CIRCLE BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4256
Practice Address - Country:US
Practice Address - Phone:541-286-4742
Practice Address - Fax:833-450-5933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130103Medicaid