Healthcare Provider Details

I. General information

NPI: 1114019494
Provider Name (Legal Business Name): LUNG CLINIC CENTER FOR SLEEP MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

874 NE 7TH ST
GRANTS PASS OR
97526-1635
US

IV. Provider business mailing address

874 NE 7TH ST
GRANTS PASS OR
97526-1635
US

V. Phone/Fax

Practice location:
  • Phone: 541-471-6026
  • Fax: 541-471-7051
Mailing address:
  • Phone: 541-471-6026
  • Fax: 541-471-7051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD16808
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberRTP000581
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00609
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD16808
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier009576
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: DEBRA A STRINGFIELD
Title or Position: OFFICE BILLING MANAGER
Credential:
Phone: 541-471-6026