MEDICARE: OREGON COAST PODIATRY, 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	213E00000X	Podiatrist	DP00365	OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DE3960	OTHER	OR	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1558545632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OREGON COAST PODIATRY, LLC

Provider Business Mailing Address
First Line	:	3229 BROADWAY ST
Second Line	:	SUITE D
City	:	NORTH BEND
State	:	OR
Zip	:	97459-2203
Country	:	US
Telephone Number	:	541-756-1190
Fax Number	:	541-756-1199

Provider Business Practice Location Address
First Line	:	3229 BROADWAY ST
Second Line	:	SUITE D
City	:	NORTH BEND
State	:	OR
Zip	:	97459-2203
Country	:	US
Telephone Number	:	541-756-1190
Fax Number	:	541-756-1199

Authorized Official
Title or Position	:	OFFICER
Name	:	SHERRY L WILLIAMS
Credential	:	DPM
Telephone Number	:	541-756-1190

Provider Enumeration Date	:	12/24/2007
Last Update Date	:	02/22/2011

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Directions to “OREGON COAST PODIATRY, LLC ” Practice Location

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