Healthcare Provider Details

I. General information

NPI: 1881674869
Provider Name (Legal Business Name): ERIC EARL COLGROVE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 CHAMBERS ST
EUGENE OR
97402-3636
US

IV. Provider business mailing address

PO BOX 1648
EUGENE OR
97440-1648
US

V. Phone/Fax

Practice location:
  • Phone: 541-338-7787
  • Fax: 541-684-3077
Mailing address:
  • Phone: 541-338-7787
  • Fax: 541-684-3077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD161353
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier286359
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier1881674869
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: