=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730441023
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELBERT C COLLINS MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2012
-----------------------------------------------------
Last Update Date | 06/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18173 REDWOOD HWY
-----------------------------------------------------
City | SELMA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-597-2464
-----------------------------------------------------
Fax | 541-597-4280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 726 NW BELLEVUE PL
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-479-9484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ DOCTOR
-----------------------------------------------------
Name | ELBERT C COLLINS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 541-479-9484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | MD14732
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------