Healthcare Provider Details

I. General information

NPI: 1275821746
Provider Name (Legal Business Name): OREGON EAR NOSE AND THROAT SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 ROYAL AVE
MEDFORD OR
97504-6169
US

IV. Provider business mailing address

920 ROYAL AVE
MEDFORD OR
97504-6169
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-7331
  • Fax: 541-779-3522
Mailing address:
  • Phone: 541-779-7331
  • Fax: 541-779-3522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. JANNEY M MARIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 541-494-0500