Provider Demographics
NPI:1790863041
Name:OREGON EAR, NOSE AND THROAT, P.C.
Entity type:Organization
Organization Name:OREGON EAR, NOSE AND THROAT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRACKEBUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-349-9333
Mailing Address - Street 1:995 WILLAGILLESPIE RD
Mailing Address - Street 2:SUITE 300C
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2186
Mailing Address - Country:US
Mailing Address - Phone:541-302-1420
Mailing Address - Fax:541-485-7881
Practice Address - Street 1:995 WILLAGILLESPIE RD
Practice Address - Street 2:SUITE 300C
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2186
Practice Address - Country:US
Practice Address - Phone:541-302-1420
Practice Address - Fax:541-485-7881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276339Medicaid
ORR112989Medicare PIN