Healthcare Provider Details

I. General information

NPI: 1063400968
Provider Name (Legal Business Name): ALDER MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 ALDER ST
BROOKINGS OR
97415-9014
US

IV. Provider business mailing address

PO BOX 5750
BROOKINGS OR
97415-0125
US

V. Phone/Fax

Practice location:
  • Phone: 541-469-5919
  • Fax: 541-469-6710
Mailing address:
  • Phone: 541-469-5919
  • Fax: 541-469-6710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD22599
License Number StateOR

VIII. Authorized Official

Name: KELLY HOUGH LOWTHER
Title or Position: PRESIDENT
Credential: MD
Phone: 541-469-5919