Provider Demographics
NPI:1952556490
Name:ENDOCRINOLOGY SERVICES NORTHWEST, LLC
Entity type:Organization
Organization Name:ENDOCRINOLOGY SERVICES NORTHWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-815-1409
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-0490
Mailing Address - Country:US
Mailing Address - Phone:541-330-2641
Mailing Address - Fax:541-388-3832
Practice Address - Street 1:2084 NE PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6077
Practice Address - Country:US
Practice Address - Phone:541-317-5600
Practice Address - Fax:541-317-5676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-25
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26567207UN0902X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR131805Medicaid
OR278317Medicaid
H86979Medicare UPIN
OR278317Medicaid
OR131805Medicaid
OR6366360001Medicare NSC