Healthcare Provider Details

I. General information

NPI: 1528015039
Provider Name (Legal Business Name): NORTHSTAR NEUROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 NE DOCTORS DR STE 9
BEND OR
97701-6324
US

IV. Provider business mailing address

2275 NE DOCTORS DR STE 9
BEND OR
97701-6324
US

V. Phone/Fax

Practice location:
  • Phone: 541-330-6463
  • Fax: 541-330-1490
Mailing address:
  • Phone: 541-330-6463
  • Fax: 541-330-1490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD LYNN KOLLER
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 541-330-6463