Healthcare Provider Details

I. General information

NPI: 1407054323
Provider Name (Legal Business Name): MEDICAL DEPARTMENT USCG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 CONNECTICUT AVE
NORTH BEND OR
97459-2300
US

IV. Provider business mailing address

MEDICAL DEPARTMENT USCG AIR STATION 2000 CONNECTICUT AVE.
NORTH BEND OR
97459-2399
US

V. Phone/Fax

Practice location:
  • Phone: 541-156-9159
  • Fax: 541-156-9617
Mailing address:
  • Phone: 541-156-9159
  • Fax: 541-156-9617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name: RADOSLAW ALEXANDER FLORCZAK
Title or Position: HEALTH TECHNICIAN
Credential:
Phone: 541-156-9159