Healthcare Provider Details

I. General information

NPI: 1043455181
Provider Name (Legal Business Name): SANTIAM MEMORIAL HOSPITAL ER GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 N 10TH AVE
STAYTON OR
97383-1311
US

IV. Provider business mailing address

1401 N 10TH AVE
STAYTON OR
97383-1311
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-2175
  • Fax: 503-769-5312
Mailing address:
  • Phone: 503-769-2175
  • Fax: 503-769-5312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0555102-0
License Number StateOR

VIII. Authorized Official

Name: MR. TERRY FLETCHALL
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 503-769-9233