Provider Demographics
NPI:1982616025
Name:SORWEIDE FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:SORWEIDE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:SORWEIDE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-955-0607
Mailing Address - Street 1:1619 NW HAWTHORNE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-6008
Mailing Address - Country:US
Mailing Address - Phone:541-955-0607
Mailing Address - Fax:
Practice Address - Street 1:1619 NW HAWTHORNE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-6008
Practice Address - Country:US
Practice Address - Phone:541-955-0607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO20800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
111397Medicare ID - Type Unspecified
OR111398Medicare ID - Type Unspecified