Healthcare Provider Details

I. General information

NPI: 1588061238
Provider Name (Legal Business Name): HEALTH ALLIANCE OF SOUTHERN OREGON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 SISKIYOU BLVD SUITE 102
MEDFORD OR
97504-8170
US

IV. Provider business mailing address

2620 E BARNETT RD SUITE H
MEDFORD OR
97504-8344
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-4728
  • Fax: 541-789-4765
Mailing address:
  • Phone: 541-789-2261
  • Fax: 541-789-2558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICK HOCKING
Title or Position: CHIEF ADMIN AND FINANCE OFFICER
Credential:
Phone: 541-789-4549