Healthcare Provider Details

I. General information

NPI: 1518103274
Provider Name (Legal Business Name): CENTENNIAL MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2008
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NW MEDICAL LOOP STE 190
ROSEBURG OR
97471-8835
US

IV. Provider business mailing address

201 NW MEDICAL LOOP STE 190
ROSEBURG OR
97471-8835
US

V. Phone/Fax

Practice location:
  • Phone: 541-644-4319
  • Fax: 541-677-2294
Mailing address:
  • Phone: 541-644-4319
  • Fax: 541-677-2294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DONNA RAYLENE VAN DIS
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 541-677-4319