Healthcare Provider Details

I. General information

NPI: 1134436637
Provider Name (Legal Business Name): CENTENNIAL MEDICAL GROUP EAST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2570 NW EDENBOWER BLVD
ROSEBURG OR
97471-6214
US

IV. Provider business mailing address

2570 NW EDENBOWER BLVD
ROSEBURG OR
97471-6214
US

V. Phone/Fax

Practice location:
  • Phone: 541-677-2494
  • Fax: 541-677-2294
Mailing address:
  • Phone: 541-677-7200
  • Fax: 541-677-7200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number71216890
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number71216890
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71216890
License Number StateOR

VIII. Authorized Official

Name: KIMBERLY TYREE
Title or Position: COO
Credential:
Phone: 541-229-3332