Provider Demographics
NPI:1982694345
Name:TREASURE VALLEY MEDICAL GROUP
Entity Type:Organization
Organization Name:TREASURE VALLEY MEDICAL GROUP
Other - Org Name:TREASURE VALLEY INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-881-7358
Mailing Address - Street 1:351 SW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2639
Mailing Address - Country:US
Mailing Address - Phone:541-881-7370
Mailing Address - Fax:541-881-7379
Practice Address - Street 1:1050 SW 3RD AVE
Practice Address - Street 2:SUITE 3200
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2193
Practice Address - Country:US
Practice Address - Phone:541-881-7370
Practice Address - Fax:541-881-7379
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLY ROSARY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-26
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDB4506OtherRAILROAD MEDICARE
OR134400OtherOMAP GROUP NUMBER
ORDB4506OtherRAILROAD MEDICARE
ORR105589Medicare PIN