Healthcare Provider Details

I. General information

NPI: 1841439312
Provider Name (Legal Business Name): JAY N. GADE M.D., PHD., PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 NW EDENBOWER BLVD.
ROSEBURG OR
97471-6220
US

IV. Provider business mailing address

2440 NW EDENBOWER BLVD.
ROSEBURG OR
97471-6220
US

V. Phone/Fax

Practice location:
  • Phone: 541-957-1141
  • Fax:
Mailing address:
  • Phone: 541-957-1141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD20360
License Number StateOR

VIII. Authorized Official

Name: JAY N GADE
Title or Position: OWNER
Credential: M.D., PHD.
Phone: 541-957-1141