Provider Demographics
NPI:1912175035
Name:SALEM CLINIC, PC
Entity type:Organization
Organization Name:SALEM CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIO/CAO
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-399-2424
Mailing Address - Street 1:PO BOX 8100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-0900
Mailing Address - Country:US
Mailing Address - Phone:503-399-2424
Mailing Address - Fax:503-375-7429
Practice Address - Street 1:2531 BOONE ROAD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306
Practice Address - Country:US
Practice Address - Phone:503-399-2424
Practice Address - Fax:503-375-7429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCS4159OtherRAILROAD MEDICARE GROUP NO
OR500400274Medicaid
OR500400274Medicaid