Healthcare Provider Details

I. General information

NPI: 1134799489
Provider Name (Legal Business Name): SMALL TOWN PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 WELCH ST
SILVERTON OR
97381-1946
US

IV. Provider business mailing address

PO BOX 1430
SILVERTON OR
97381-0106
US

V. Phone/Fax

Practice location:
  • Phone: 503-400-3852
  • Fax: 503-334-2268
Mailing address:
  • Phone: 503-400-3852
  • Fax: 503-334-2268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500675213
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: DR. DOUGLAS SCOTT HAMBLIN
Title or Position: OWNER/PEDIATRICIAN
Credential: MD
Phone: 971-304-9855