MEDICARE: EMURGENT CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	DO27917	OR
2	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1265871123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMURGENT CARE LLC

Provider Business Mailing Address
First Line	:	109 E ELLENDALE AVE STE B
Second Line	:
City	:	DALLAS
State	:	OR
Zip	:	97338-1509
Country	:	US
Telephone Number	:	503-623-3199
Fax Number	:	503-623-3398

Provider Business Practice Location Address
First Line	:	109 E ELLENDALE AVE STE B
Second Line	:
City	:	DALLAS
State	:	OR
Zip	:	97338-1509
Country	:	US
Telephone Number	:	503-623-3199
Fax Number	:	503-623-3398

Authorized Official
Title or Position	:	OWNER
Name	:	CRYSTAL HASINA KOHISTANI
Credential	:	PA-C
Telephone Number	:	612-306-7403

Provider Enumeration Date	:	06/24/2013
Last Update Date	:	08/01/2022

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Directions to “EMURGENT CARE LLC ” Practice Location

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