NPIMap

Organization Active NPI

Centennial Medical Group East, LLC

  • Obstetrics & Gynecology Physician
  • Roseburg, OR
National Provider Identifier
1134243249
Registry record updated May 1, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X
Legal business name
CENTENNIAL MEDICAL GROUP EAST, LLC
Practice address
1937 W Harvard Ave
Roseburg, OR 97471-2720
Phone
(541) 677-7200
Fax
(541) 229-3309
NPI assigned
Mar 16, 2007
Last updated
May 1, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 1, 2020

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

Authorized official

Name
Kimberly Tyree
Title
Coo
Phone
(541) 229-3332

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Obstetrics & Gynecology Physician 207V00000X OR Primary

Addresses

Primary practice location

1937 W Harvard Ave
Roseburg, OR 97471-2720

Mailing address

2570 NW Edenbower Blvd
Roseburg, OR 97471-6214
Phone (541) 677-7200

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120228000510 OR Part B Supplier - Clinic/Group Practice 9234397878 Receives reassigned benefits from 75 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Myrtle Creek, OR; Roseburg, OR; Sutherlin, OR

Other NPIs on the same Medicare enrollment 5

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

National Provider Directory

National Provider Directory
Tax ID family
Centennial Medical Group East LLC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

2570 NW Edenbower Blvd
Ste 100
Roseburg, OR 97471
Phone (541) 677-7200

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1174003200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1588291200000",
    "number": "1134243249",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2570 NW EDENBOWER BLVD",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974716214",
            "telephone_number": "541-677-7200",
            "fax_number": "541-677-7462"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1937 W HARVARD AVE",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974712720",
            "telephone_number": "541-677-7200",
            "fax_number": "541-229-3309"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTENNIAL MEDICAL GROUP EAST, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-16",
        "last_updated": "2020-05-01",
        "certification_date": "2020-05-01",
        "status": "A",
        "authorized_official_last_name": "TYREE",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "541-229-3332"
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "OR",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Roseburg, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2020; 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.