Healthcare Provider Details

I. General information

NPI: 1346578861
Provider Name (Legal Business Name): DOUGLAS MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 W HARVARD AVE SUITES 110, 201, 422, 426
ROSEBURG OR
97471-2752
US

IV. Provider business mailing address

1813 W HARVARD AVE SUITE 448
ROSEBURG OR
97471-2752
US

V. Phone/Fax

Practice location:
  • Phone: 541-957-3079
  • Fax: 541-464-4641
Mailing address:
  • Phone: 541-957-3079
  • Fax: 541-464-4641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. JAMIE L WARNER
Title or Position: ASSISTANT MANAGER
Credential:
Phone: 547-957-3079