Healthcare Provider Details

I. General information

NPI: 1427296623
Provider Name (Legal Business Name): ROGUE VALLEY EAR, NOSE, THROAT & FACIAL PLASTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2009
Last Update Date: 01/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 NE 6TH ST
GRANTS PASS OR
97526-1035
US

IV. Provider business mailing address

1601 NE 6TH ST
GRANTS PASS OR
97526-1035
US

V. Phone/Fax

Practice location:
  • Phone: 541-479-2600
  • Fax: 541-479-2990
Mailing address:
  • Phone: 541-479-2600
  • Fax: 541-479-2990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY A KOZAK
Title or Position: OWNER
Credential: D.O.
Phone: 541-479-2600