NPIMap

Organization Active NPI

WVP Medical Group, LLC

  • Primary Care Clinic/Center
  • Salem, OR
National Provider Identifier
1124352877
Registry record updated Apr 19, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
WVP MEDICAL GROUP, LLC
Practice address
2485 12TH St SE
Salem, OR 97302-2151
Phone
(503) 363-8047
Fax
(503) 363-6571
NPI assigned
Sep 29, 2009
Organization subpart
Yes
Parent organization
MID VALLEY IPA INC. (WVP HEALTH AUTHORITY)As reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 19, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Dean G. Andretta
Title
Cfo
Phone
(503) 371-7701

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Obesity Medicine (Family Medicine) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207QB0002X
Primary Care Clinic/Center 261QP2300X Primary

Addresses

Primary practice location

2485 12TH St SE
Salem, OR 97302-2151

Mailing address

2995 Ryan Dr SE
Ste. 200
Salem, OR 97301-5157
Phone (503) 371-7701

Other practice location 1

2525 12th St SE, Ste 260
Salem, OR 97302-2153
Phone (503) 363-6520

Other identifiers 2

IdentifierTypeStateIssuer
R151720OtherORPTAN
288533MedicaidOR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100209000818 OR Part B Supplier - Clinic/Group Practice 4486627965 Receives reassigned benefits from 3 practitioners
8 other NPIs on this enrollment
Practice locations: Salem, OR

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 8

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

2995 Ryan Dr SE
Ste 200
Salem, OR 97301
Phone (503) 371-7701

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1254182400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1524096000000",
    "number": "1124352877",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2995 RYAN DR SE",
            "address_2": "STE. 200",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973015157",
            "telephone_number": "503-371-7701"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2485 12TH ST SE",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973022151",
            "telephone_number": "503-363-8047",
            "fax_number": "503-363-6571"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2525 12th St SE, Ste 260",
            "address_purpose": "LOCATION",
            "city": "Salem",
            "state": "OR",
            "postal_code": "973022153",
            "country_code": "US",
            "telephone_number": "503-363-6520",
            "fax_number": "503-967-1472",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "WVP MEDICAL GROUP, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MID VALLEY IPA  INC. (WVP HEALTH AUTHORITY)",
        "enumeration_date": "2009-09-29",
        "last_updated": "2018-04-19",
        "status": "A",
        "authorized_official_last_name": "ANDRETTA",
        "authorized_official_first_name": "DEAN",
        "authorized_official_middle_name": "G.",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "503-371-7701",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207QB0002X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine, Obesity Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN",
            "identifier": "R151720",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "288533",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Salem, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 19, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.