Healthcare Provider Details

I. General information

NPI: 1699103598
Provider Name (Legal Business Name): CENTENNIAL MEDICAL GROUP EAST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2013
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 NE BROADWAY ST
MYRTLE CREEK OR
97457-9039
US

IV. Provider business mailing address

2801 NW MERCY DR SUITE 340
ROSEBURG OR
97471-2348
US

V. Phone/Fax

Practice location:
  • Phone: 541-863-3146
  • Fax: 541-863-3226
Mailing address:
  • Phone: 541-677-2494
  • Fax: 541-677-2294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71216890
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: KIM TYREE
Title or Position: COO
Credential:
Phone: 541-229-3332