Provider Demographics
NPI:1811175565
Name:MT. EMILY MEDICAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:MT. EMILY MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:HILARN
Authorized Official - Last Name:DUVERNAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD, FACP
Authorized Official - Phone:541-805-9831
Mailing Address - Street 1:204 3RD ST
Mailing Address - Street 2:P.O. BOX 2994
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1946
Mailing Address - Country:US
Mailing Address - Phone:541-605-0330
Mailing Address - Fax:541-605-0330
Practice Address - Street 1:204 3RD ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1946
Practice Address - Country:US
Practice Address - Phone:541-605-0330
Practice Address - Fax:541-605-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2014-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15649207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty