CENTENNIAL MEDICAL GROUP EAST, LLC (NPI# 1992183859) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1992183859 |
| Entity Type | Organization |
| Organization Name | CENTENNIAL MEDICAL GROUP EAST, LLC |
| Other Organization Name | EVERGREEN FAMILY MEDICINE SOUTH |
| Practice Address |
145 E. Broadway Myrtle Creek OR 97457 |
| Mailing Address |
2801 Nw Mercy Drive Suite 340 Roseburg OR 97471 |
| Practice Telephone | 5418633146 |
| Practice Fax Number | 5418633226 |
| Mailing Telephone | 5416772494 |
| Mailing Fax Number | 5416772294 |
| Enumeration Date | 2015-05-12 |
| Last Update Date | 2015-07-16 |
| Authorized Official Name | JASON GRAY (PRESIDENT) |
| Authorized Official Telephone | 5416772494 |
| Authorized Official Credential | MD |
| Is Organization Subpart | Y |
| Parent Organization Name | CENTENNIAL MEDICAL GROUP, EAST, LLC |
| Parent Organization TIN |
|
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 261QR1300X |
Clinic/Center Specialization: Rural Health |
OR | Ambulatory Health Care Facilities |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| OR | 500680156 | 05 |
| Other Name | Type Code |
|---|---|
| Evergreen Family Medicine South | Doing Business As Name - Organization |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1083113245 | Centennial Medical Group East, LLC | Family Medicine | 2510 Nw Edenbower Blvd Ste 152, Roseburg, OR 97471-8899 | 2018-02-02 |
| 1235688805 | Centennial Medical Group East, LLC | Family Medicine | 1937 W Harvard Ave, Roseburg, OR 97471-2720 | 2016-09-23 |
| 1699103598 | Centennial Medical Group East, LLC | Family Medicine | 145 Ne Broadway St, Myrtle Creek, OR 97457-9039 | 2013-10-31 |
| 1821366071 | Centennial Medical Group East, LLC | Clinic/Center | 2570 Nw Edenbower Blvd, Roseburg, OR 97471-6214 | 2011-12-02 |
| 1164730719 | Centennial Medical Group East, LLC | Emergency Medicine | 2570 Nw Edenbower Blvd, Roseburg, OR 97471-6214 | 2010-09-16 |
| 1134436637 | Centennial Medical Group East, LLC | Emergency Medicine | 2570 Nw Edenbower Blvd, Roseburg, OR 97471-6214 | 2010-09-03 |
| 1134243249 | Centennial Medical Group East, LLC | Obstetrics & Gynecology | 1937 W Harvard Ave, Roseburg, OR 97471-2720 | 2007-03-16 |
| Entity Type | Entity Name | Entity Address |
|---|---|---|
| System for Award Management (SAM) Entities | CENTENNIAL MEDICAL GROUP EAST, LLC | 2801 Nw Mercy Dr Ste 340, Roseburg, OR 97471-2348 |
| Oregon Corporations, Companies and Business Names | CENTENNIAL MEDICAL GROUP EAST, LLC | 2570 Nw Edenbower Blvd, Roseburg, OR 97471 |
| Street Address |
145 E. BROADWAY |
| City | MYRTLE CREEK |
| State | OR |
| Zip Code | 97457 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1629542626 | Reva Jeanne Whitson | Massage Therapist | 837 N Main St., Myrtle Creek, OR 97457 | 2019-01-14 |
| 1235619578 | Mark Francis Kleinschmidt | Massage Therapist | 213 S.pacific Hwy., St. 101, Myrtle Creek, OR 97457 | 2018-08-16 |
| 1356504443 | Jd Tucker Rohm | Chiropractor | 213 So. Old Pacific Highway, Suite 101, Myrtle Creek, OR 97457 | 2008-07-08 |
| 1295998920 | Paula Jo Cramer | Nurse Practitioner | 790 S Main St Myrtle, Creek, Ore, Myrtle Creek, OR 97457 | 2008-07-02 |
| 1952529810 | Jackie J Sochin | Nurse Practitioner | 790 S. Main, Myrtle Creek, OR 97457 | 2007-04-23 |
| 1255480786 | James A. Lawson Jr. | Dentist | 434 N. E. 2nd St., Myrtle Creek, OR 97457 | 2007-01-10 |
| 1194809921 | Kenneth Lee Mills | Dentist | 244 Ne Division, Myrtle Creek, OR 97457 | 2006-10-25 |
| 1164516365 | Jaime Francisco Serranzana | General Practice | 925 Nw Pacific Hwy, Myrtle Creek, OR 97457 | 2006-10-03 |
| 1407968472 | Lynn E Goodwin | Optometrist | 425 N Main, Myrtle Creek, OR 97457 | 2006-08-31 |
| 1265457808 | Anna Marie Hansen | Physical Therapist | 213 Nw 2nd Ave, Myrtle Creek, OR 97457 | 2006-07-13 |
| Find all providers in zip 97457 | ||||
| Taxonomy Code | 261QR1300X |
| Grouping | Ambulatory Health Care Facilities |
| Classification | Clinic/Center |
| Specialization | Rural Health |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1770183063 | Praxis Medical Group P.C. | Clinic/Center | 1890 7th St., Umatilla, OR 97882 | 2020-10-27 |
| 1336749621 | Praxis Medical Group P.C. | Clinic/Center | 2011 Fourth St., La Grande, OR 97850 | 2020-10-27 |
| 1225694706 | Columbia Lutheran Charities | Clinic/Center | 1111 N Roosevelt Dr Ste 210, Seaside, OR 97138-4604 | 2019-05-10 |
| 1093296519 | Grande Ronde Hospital, Inc. | Clinic/Center | 10303 S Walton Rd, La Grande, OR 97850 | 2018-08-23 |
| 1285164921 | Northwest Medical Foundation of Tillamook | Clinic/Center | 1005 Cougar St, Vernonia, OR 97064-1282 | 2017-06-15 |
| 1043694342 | Grande Ronde Hospital, Inc | Clinic/Center | 570 8th, Elgin, OR 97827 | 2015-07-16 |
| 1477945517 | Morrow County Health District | Clinic/Center | 365 W 3rd St, Ione, OR 97843-7216 | 2015-02-26 |
| 1699183236 | Lake Health District | Clinic/Center | 700 South J St, Lakeview, OR 97630 | 2014-07-28 |
| 1487919783 | Aurora Family Health and Maternity Care Services LLC | Clinic/Center | 21358 Hwy 99e Ne, Aurora, OR 97002 | 2012-07-12 |
| 1508122763 | Mid-valley Healthcare, Inc. | Clinic/Center | 35 Mullins Drive, Suite 2, Lebanon, OR 97355 | 2012-04-02 |
| Find all providers with the same taxonomy | ||||
| City | MYRTLE CREEK |
| Zip Code | 97457 |
Please comment or provide details below to improve the information on CENTENNIAL MEDICAL GROUP EAST, LLC.
| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.