Healthcare Provider Details

I. General information

NPI: 1073710778
Provider Name (Legal Business Name): CARRIE ATWELL GANONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 DAGGETT AVE
KLAMATH FALLS OR
97601-1114
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 541-851-4800
  • Fax: 541-851-4801
Mailing address:
  • Phone: 605-328-6585
  • Fax: 605-328-6512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number44131
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier64958960
Identifier TypeMEDICAID
Identifier StateKY
Identifier Issuer
# 2
Identifier01325653
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: