Provider Demographics
NPI:1174053094
Name:NORTHWEST MEDICAL HOMES, LLC
Entity type:Organization
Organization Name:NORTHWEST MEDICAL HOMES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-747-4300
Mailing Address - Street 1:2280 MARCOLA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-2594
Mailing Address - Country:US
Mailing Address - Phone:541-747-4300
Mailing Address - Fax:541-284-5534
Practice Address - Street 1:2644 SUZANNE WAY
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408-7418
Practice Address - Country:US
Practice Address - Phone:541-747-4300
Practice Address - Fax:541-747-0655
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST MEDICAL HOMES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150270Medicaid