Healthcare Provider Details

I. General information

NPI: 1770608424
Provider Name (Legal Business Name): US COAST GUARD MEDICAL CLINIC NORTH BEND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
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

2000 CONNECTICUT AVE
NORTH BEND OR
97459-2300
US

V. Phone/Fax

Practice location:
  • Phone: 541-756-9234
  • Fax: 541-756-9617
Mailing address:
  • Phone: 541-756-9234
  • Fax: 541-756-9617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number35057309
License Number StateOH

VIII. Authorized Official

Name: MR. STEPHEN J KINSLEY
Title or Position: SENIOR MEDICAL OFFICER
Credential: M.D.
Phone: 541-756-9237