=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104586726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THREE OAKS ANESTHESIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2021
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 633 WAVERLY DR SE
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97322-5078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-286-2309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 28
-----------------------------------------------------
City | CORVALLIS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97339-0028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-704-7999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | DR. JARED DALE GROSE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 541-232-3491
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------