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General NPI Number Information
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NPI Number | 1518103274
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Entity Type | Organization
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Legal Business Name | CENTENNIAL MEDICAL GROUP INC.
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Dates
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Enumeration Date | 12/31/2008
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Last Update Date | 11/25/2019
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Provider Practice Location Address
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Address Line | 201 NW MEDICAL LOOP STE 190
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City | ROSEBURG
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State | OR
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Zip | 97471-8835
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Country | US
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Telephone | 541-644-4319
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Fax | 541-677-2294
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Provider Business Mailing Address
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Address Line | 201 NW MEDICAL LOOP STE 190
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City | ROSEBURG
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State | OR
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Zip | 97471-8835
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Country | US
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Telephone | 541-644-4319
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Fax | 541-677-2294
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | DONNA RAYLENE VAN DIS
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Credential |
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Telephone | 541-677-4319
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207RS0012X
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Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207ZP0105X
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Taxonomy Name | Clinical Pathology/Laboratory Medicine Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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