Healthcare Provider Details

I. General information

NPI: 1518171339
Provider Name (Legal Business Name): INTERNAL MEDICINE & GERIATRICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3369 NE STEPHENS ST. STE. 100
ROSEBURG OR
97470
US

IV. Provider business mailing address

3369 NE STEPHENS ST. STE 100
ROSEBURG OR
97470
US

V. Phone/Fax

Practice location:
  • Phone: 541-677-8900
  • Fax: 541-677-8900
Mailing address:
  • Phone: 541-677-8900
  • Fax: 541-677-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number24877
License Number StateOR

VIII. Authorized Official

Name: RANGANATHAN RAJENDRAN
Title or Position: MD
Credential: MD
Phone: 541-677-8900