NPIMap

Organization Active NPI

Centennial Medical Group East, LLC

  • Family Medicine Physician
  • Roseburg, OR
National Provider Identifier
1134436637
Registry record updated Jul 1, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
71216890 Issued in OR
Legal business name
CENTENNIAL MEDICAL GROUP EAST, LLC
Practice address
2570 NW Edenbower Blvd
Roseburg, OR 97471-6214
Phone
(541) 677-2494
Fax
(541) 677-2294
NPI assigned
Sep 3, 2010
Organization subpart
Yes
Parent organization
CENTENNIAL MEDICAL GROUP, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 1, 2025

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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207P00000X 71216890 OR
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X 71216890 OR Primary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X 71216890 OR

Addresses

Primary practice location

2570 NW Edenbower Blvd
Roseburg, OR 97471-6214

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
Practice locations: Myrtle Creek, OR; Roseburg, OR; Sutherlin, OR

Other NPIs with the same Medicare PAC ID 4

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

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
Part of
Centennial Medical Group

Practitioners & affiliated clinicians

Practitioners 76

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

View all 76

NPI Registry JSON

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

{
    "created_epoch": "1283472000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751328000000",
    "number": "1134436637",
    "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": "541-677-7200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2570 NW EDENBOWER BLVD",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974716214",
            "telephone_number": "541-677-2494",
            "fax_number": "541-677-2294"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTENNIAL MEDICAL GROUP EAST, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTENNIAL MEDICAL GROUP, INC.",
        "enumeration_date": "2010-09-03",
        "last_updated": "2025-07-01",
        "certification_date": "2025-07-01",
        "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": "207P00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Emergency Medicine",
            "state": "OR",
            "license": "71216890",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "OR",
            "license": "71216890",
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": "OR",
            "license": "71216890",
            "primary": false
        }
    ],
    "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 Jul 1, 2025; 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.