Healthcare Provider Details

I. General information

NPI: 1639159916
Provider Name (Legal Business Name): GI ENDOSCOPY CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2560 NW MEDICAL PARK DR
ROSEBURG OR
97470-5510
US

IV. Provider business mailing address

2560 NW MEDICAL PARK DR
ROSEBURG OR
97470-5510
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-2046
  • Fax: 541-673-0454
Mailing address:
  • Phone: 541-673-2046
  • Fax: 541-673-0454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number071432
License Number StateOR

VIII. Authorized Official

Name: DEBORAH D DIXON
Title or Position: ASSISTANT ADMINISTRATOR
Credential:
Phone: 541-957-7734