Organization
CENTENNIAL MEDICAL GROUP INC.
Active
Parent organization
CENTENNIAL MEDICAL GROUP INC.
Organization subpart
Yes
Provider details
NPI number
Legal business name
CENTENNIAL MEDICAL GROUP INC.
Authorized official
DONNA RAYLENE VAN DIS (CREDENTIALING COORDINATOR)
(541) 677-4319
Entity
Organization
Contact information
Practice address
201 NW MEDICAL LOOP STE 190, ROSEBURG, OR 97471-8835
(541) 644-4319
(541) 677-2294
Mailing address
201 NW MEDICAL LOOP STE 190, ROSEBURG, OR 97471-8835
(541) 644-4319
(541) 677-2294
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
—
—
207RG0100X
Gastroenterology Physician
—
—
207RP1001X
Pulmonary Disease Physician
—
—
207RS0012X
Sleep Medicine (Internal Medicine) Physician
—
—
207ZP0105X
Clinical Pathology/Laboratory Medicine Physician
—
—
208600000X
Surgery Physician
Primary
—
—
208800000X
Urology Physician
—
—
208M00000X
Hospitalist Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500601997
—
OR
Enumeration date
12/31/2008
Last updated
11/25/2019
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