MEDICARE: OREGON ENDOSCOPY CENTER, LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center	071536	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366449910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OREGON ENDOSCOPY CENTER, LLC

Provider Business Mailing Address
First Line	:	3355 RIVERBEND DR
Second Line	:	SUITE 510
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-8800
Country	:	US
Telephone Number	:	541-868-9555
Fax Number	:	541-868-9556

Provider Business Practice Location Address
First Line	:	3355 RIVERBEND DR
Second Line	:	SUITE 510
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-8800
Country	:	US
Telephone Number	:	541-868-9555
Fax Number	:	541-868-9556

Authorized Official
Title or Position	:	MEDICAL DIRECTOR/PHYSICIAN PARTNER
Name	:	DR. JONATHAN GONENNE
Credential	:	MD
Telephone Number	:	541-868-9555

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	07/06/2015

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