Healthcare Provider Details

I. General information

NPI: 1194902502
Provider Name (Legal Business Name): SAMUEL ADEN HIRTLE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 S FRONT ST STE 200
CENTRAL POINT OR
97502-2779
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 541-664-3346
  • Fax: 541-664-6051
Mailing address:
  • Phone: 541-664-3346
  • Fax: 541-664-6051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP60409596
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOL60286768
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO171203
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: