MEDICARE: COLUMBIA GORGE ENT, 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	207Y00000X	Otolaryngology Physician	MD10654	OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	DB9629	OTHER	OR	RAILROAD MEDICARE

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427056324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBIA GORGE ENT, LLC

Provider Business Mailing Address
First Line	:	1815 E 19TH ST
Second Line	:	SUITE 1
City	:	THE DALLES
State	:	OR
Zip	:	97058-3365
Country	:	US
Telephone Number	:	541-298-5563
Fax Number	:	541-298-7746

Provider Business Practice Location Address
First Line	:	1815 E 19TH ST
Second Line	:	SUITE 1
City	:	THE DALLES
State	:	OR
Zip	:	97058-3365
Country	:	US
Telephone Number	:	541-298-5563
Fax Number	:	541-298-7746

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHARLES R FORD
Credential	:	MD
Telephone Number	:	541-298-5563

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	08/23/2007

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