Healthcare Provider Details

I. General information

NPI: 1780846501
Provider Name (Legal Business Name): BEND MEMORIAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 NE NEFF RD
BEND OR
97701-6337
US

IV. Provider business mailing address

1501 NE MEDICAL CENTER DR
BEND OR
97701-6051
US

V. Phone/Fax

Practice location:
  • Phone: 541-322-3504
  • Fax:
Mailing address:
  • Phone: 541-382-2811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier231243
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: GREGORY HAGFORS
Title or Position: CEO
Credential:
Phone: 541-706-5401