Healthcare Provider Details

I. General information

NPI: 1962090621
Provider Name (Legal Business Name): MARY LOU FREITAG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 4TH ST
MYRTLE POINT OR
97458-1074
US

IV. Provider business mailing address

1900 WOODLAND DR
COOS BAY OR
97420-2099
US

V. Phone/Fax

Practice location:
  • Phone: 541-572-2111
  • Fax:
Mailing address:
  • Phone: 541-267-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number202010537NP-PP
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier500789478
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: