Healthcare Provider Details

I. General information

NPI: 1952556490
Provider Name (Legal Business Name): ENDOCRINOLOGY SERVICES NORTHWEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2084 NE PROFESSIONAL CT
BEND OR
97701-6077
US

IV. Provider business mailing address

PO BOX 490
BEND OR
97709-0490
US

V. Phone/Fax

Practice location:
  • Phone: 541-317-5600
  • Fax: 541-317-5676
Mailing address:
  • Phone: 541-330-2641
  • Fax: 541-388-3832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD26567
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License NumberMD26567
License Number StateOR

VIII. Authorized Official

Name: DANIEL MICHAEL MCCARTHY
Title or Position: MANAGER
Credential:
Phone: 541-815-1409