Healthcare Provider Details

I. General information

NPI: 1427056324
Provider Name (Legal Business Name): COLUMBIA GORGE ENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 E 19TH ST SUITE 1
THE DALLES OR
97058-3365
US

IV. Provider business mailing address

1815 E 19TH ST SUITE 1
THE DALLES OR
97058-3365
US

V. Phone/Fax

Practice location:
  • Phone: 541-298-5563
  • Fax: 541-298-7746
Mailing address:
  • Phone: 541-298-5563
  • Fax: 541-298-7746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD10654
License Number StateOR

VIII. Authorized Official

Name: DR. CHARLES R FORD
Title or Position: OWNER
Credential: MD
Phone: 541-298-5563