Healthcare Provider Details

I. General information

NPI: 1588674279
Provider Name (Legal Business Name): NORTHWEST MEDICAL SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 NE WYATT CT SUITE #201
BEND OR
97701-7678
US

IV. Provider business mailing address

2115 NE WYATT CT SUITE #201
BEND OR
97701-7678
US

V. Phone/Fax

Practice location:
  • Phone: 541-585-2400
  • Fax: 541-585-2407
Mailing address:
  • Phone: 541-585-2400
  • Fax: 541-585-2407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. KENT YUNDT
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 541-585-2400