Provider Demographics
NPI:1750699542
Name:SOUTHERN OREGON COLON AND RECTAL SURGICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:SOUTHERN OREGON COLON AND RECTAL SURGICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-479-8308
Mailing Address - Street 1:520 SW RAMSEY AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5535
Mailing Address - Country:US
Mailing Address - Phone:541-479-8308
Mailing Address - Fax:541-474-0447
Practice Address - Street 1:520 SW RAMSEY AVE STE 204
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5535
Practice Address - Country:US
Practice Address - Phone:541-479-8308
Practice Address - Fax:541-474-0447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO29287208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR234880Medicaid
C91647Medicare UPIN