Provider Demographics
NPI:1912944067
Name:BROOKINGS HARBOR MEDICAL CENTER P C
Entity Type:Organization
Organization Name:BROOKINGS HARBOR MEDICAL CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-469-6023
Mailing Address - Street 1:PO BOX 5870
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0234
Mailing Address - Country:US
Mailing Address - Phone:541-469-7401
Mailing Address - Fax:541-469-7083
Practice Address - Street 1:446 OAK ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-0234
Practice Address - Country:US
Practice Address - Phone:541-469-7401
Practice Address - Fax:541-469-7083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134055Medicaid
OR0657680001Medicare NSC
OR134055Medicaid