Healthcare Provider Details

I. General information

NPI: 1659442960
Provider Name (Legal Business Name): EUGENE PEDIATRIC ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 WILLAGILLESPIE RD SUITE 100
EUGENE OR
97401-2186
US

IV. Provider business mailing address

995 WILLAGILLESPIE RD SUITE 100
EUGENE OR
97401-2186
US

V. Phone/Fax

Practice location:
  • Phone: 541-484-5443
  • Fax: 541-687-5621
Mailing address:
  • Phone: 541-484-5443
  • Fax: 541-687-5621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD09583
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MRS. MARYANN POTTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-484-5443