Healthcare Provider Details

I. General information

NPI: 1780933952
Provider Name (Legal Business Name): GREGG V. KOSLOFF PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3377 RIVERBEND DR
SPRINGFIELD OR
97477-8803
US

IV. Provider business mailing address

3355 RIVERBEND DR STE 300
SPRINGFIELD OR
97477-8800
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-2700
  • Fax: 541-222-6113
Mailing address:
  • Phone: 541-868-9303
  • Fax: 541-868-9306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA159940
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: