Provider Demographics
NPI:1033654793
Name:PHOENIX RISING FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:PHOENIX RISING FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DUPUIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-556-6743
Mailing Address - Street 1:PO BOX 2693
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97308-2693
Mailing Address - Country:US
Mailing Address - Phone:541-556-6743
Mailing Address - Fax:
Practice Address - Street 1:810 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:971-227-1073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-04
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201505391NP-PP261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500690272Medicaid
ORR185124OtherMEDICARE PTAN