MEDICARE: TREASURE VALLEY MEDICAL GROUP

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	261QM2500X	Medical Specialty Clinic/Center		OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DB4506	OTHER	OR	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	134400	OTHER	OR	OMAP GROUP NUMBER

General Provider Information

NPI Number	:	1982694345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TREASURE VALLEY MEDICAL GROUP

Provider Business Mailing Address
First Line	:	351 SW 9TH ST
Second Line	:
City	:	ONTARIO
State	:	OR
Zip	:	97914-2639
Country	:	US
Telephone Number	:	541-881-7370
Fax Number	:	541-881-7379

Provider Business Practice Location Address
First Line	:	1050 SW 3RD AVE
Second Line	:	SUITE 3200
City	:	ONTARIO
State	:	OR
Zip	:	97914-2193
Country	:	US
Telephone Number	:	541-881-7370
Fax Number	:	541-881-7379

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	HEATHER LYNN RIVERA
Credential	:
Telephone Number	:	541-881-7358

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	12/21/2007

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Directions to “TREASURE VALLEY MEDICAL GROUP ” Practice Location

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