Healthcare Provider Details

I. General information

NPI: 1982148789
Provider Name (Legal Business Name): WVP MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 SKYLINE VILLAGE LOOP S
SALEM OR
97306-9490
US

IV. Provider business mailing address

2995 RYAN DR SE STE 200
SALEM OR
97301-5157
US

V. Phone/Fax

Practice location:
  • Phone: 503-391-1110
  • Fax: 503-370-4237
Mailing address:
  • Phone: 503-371-7701
  • Fax:

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 Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. DEAN ANDRETTA
Title or Position: CFO
Credential:
Phone: 503-371-7701