Healthcare Provider Details

I. General information

NPI: 1992973622
Provider Name (Legal Business Name): SALEM CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 INLAND SHORES WAY N
KEIZER OR
97303-3795
US

IV. Provider business mailing address

PO BOX 8100
SALEM OR
97303-0900
US

V. Phone/Fax

Practice location:
  • Phone: 503-399-2424
  • Fax:
Mailing address:
  • Phone: 503-399-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
IdentifierCS4159
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerRAILROAD MEDICARE NO.
# 2
IdentifierR0000WCJWK
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerMEDICARE PTAN
# 3
Identifier500400276
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MS. BARBARA GUNDER
Title or Position: ADMINISTRATOR/CAO
Credential:
Phone: 503-399-2470