Healthcare Provider Details

I. General information

NPI: 1518285915
Provider Name (Legal Business Name): PDH FAMILY MEDICAL HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 05/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 LANCASTER DR SE
SALEM OR
97317-5643
US

IV. Provider business mailing address

581 LANCASTER DR SE # 288
SALEM OR
97317-5642
US

V. Phone/Fax

Practice location:
  • Phone: 503-399-7474
  • Fax: 503-399-0679
Mailing address:
  • Phone: 503-399-7474
  • Fax: 503-399-0679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD26240
License Number StateOR

VIII. Authorized Official

Name: DR. PHYLLIS D HURSEY
Title or Position: OWNER
Credential: MD FAAFP
Phone: 503-399-7474