MEDICARE: MAURICE COLLADA JR. MD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MD13614	OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103728	OTHER		MEDICARE

General Provider Information

NPI Number	:	1285813071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAURICE COLLADA JR. MD PC

Provider Business Mailing Address
First Line	:	1344 LIBERTY ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-4283
Country	:	US
Telephone Number	:	503-581-5517
Fax Number	:	503-581-6341

Provider Business Practice Location Address
First Line	:	1344 LIBERTY ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-4283
Country	:	US
Telephone Number	:	503-581-5517
Fax Number	:	503-581-6341

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KHRISTY SPAETH
Credential	:
Telephone Number	:	503-581-5517

Provider Enumeration Date	:	10/29/2007
Last Update Date	:	07/27/2010

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