NPIMap

Organization Active NPI

Centennial Medical Group East, LLC

Doing business as Evergreen Family Medicine North

  • Family Medicine Physician
  • Sutherlin, OR
National Provider Identifier
1164124111
Registry record updated Mar 21, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CENTENNIAL MEDICAL GROUP EAST, LLC
Doing business as
Evergreen Family Medicine North
Practice address
249 Dakota St
Sutherlin, OR 97479-9908
Phone
(541) 677-7200
Fax
(541) 229-3309
NPI assigned
Mar 21, 2023
Last updated
Mar 21, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
CENTENNIAL MEDICAL GROUP EAST, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 21, 2023

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

Authorized official

Name
Kimberly Tyree
Title
Chief Operating Officer
Phone
(541) 229-3332

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

249 Dakota St
Sutherlin, OR 97479-9908

Mailing address

2570 NW Edenbower Blvd Ste 100
Roseburg, OR 97471-6214
Phone (541) 677-7200

Other names 1

  • Evergreen Family Medicine North Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR2 enrollments

Enrollment records 2

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
O20230419000638 OR Part A Provider - Rural Health Clinic 9234397878 Practice locations: Sutherlin, OR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1164124111. Details of each certification follow.

Rural health clinic certification: CCN 383917

Legal name
CENTENNIAL MEDICAL GROUP EAST LLC
Doing business as
EVERGREEN FAMILY MEDICINE-NORTH
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 24, 2023
Last certification
May 14, 2026
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
in OR
Enrollment address
249 Dakota St
Sutherlin, OR 97479-9908

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.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
38D2280627Centennial Medical Group East Dba249 Dakota Street, Sutherlin, OR 97479Certificate of waiverApr 23, 2027

National Provider Directory

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

Other organizations with this tax ID 4

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

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

1813 W Harvard Ave
Ste 542
Roseburg, OR 97471
Phone (541) 440-5222

Ownership & related parties

All disclosed owners & managing parties 7

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Timothy J Powell Individual 5% Or Greater Direct Ownership Interest Nov 30, 2022 57%
General Partnership InterestCeo Nov 30, 2022 57%
Corporate OfficerCeo Nov 30, 2022 57%
Christine a Yarbrough Individual W-2 Managing EmployeeCredentialing Director Nov 22, 2022 5%
Kimberly K Tyree Individual Corporate OfficerChief Operations Officer Nov 30, 2022 50%
Operational/Managerial ControlChief Operations Officer Nov 30, 2022 50%
John L Powell Individual 5% Or Greater Direct Ownership Interest Nov 30, 2022 27%
General Partnership InterestCmo Nov 30, 2022 27%
Corporate OfficerCmo Nov 30, 2022 27%
Centennial Medical Group Inc Organization, Roseburg, OR Corporation, Non-profit 5% Or Greater Direct Ownership Interest Sep 2, 2010 100%
Powell Property Holdings, LLC Organization, Sutherlin, OR Created for acquisition, LLC 5% Or Greater Direct Ownership Interest Nov 30, 2022 100%
5% Or Greater Mortgage Interest Nov 30, 2022 100%
Mary E Powell Individual 5% Or Greater Direct Ownership Interest Nov 30, 2022 13%
General Partnership InterestCmo for Women's Health Nov 30, 2022 13%
Corporate OfficerCmo for Women's Health Nov 30, 2022 13%

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 66

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.

View all 66

NPI Registry JSON

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

{
    "created_epoch": "1679356800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1679356800000",
    "number": "1164124111",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2570 NW EDENBOWER BLVD STE 100",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974716214",
            "telephone_number": "541-677-7200",
            "fax_number": "541-229-3309"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "249 DAKOTA ST",
            "city": "SUTHERLIN",
            "state": "OR",
            "postal_code": "974799908",
            "telephone_number": "541-677-7200",
            "fax_number": "541-229-3309"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTENNIAL MEDICAL GROUP EAST, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTENNIAL MEDICAL GROUP EAST, LLC",
        "enumeration_date": "2023-03-21",
        "last_updated": "2023-03-21",
        "certification_date": "2023-03-21",
        "status": "A",
        "authorized_official_last_name": "TYREE",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "CHIEF OPERATING OFFICER",
        "authorized_official_telephone_number": "541-229-3332"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Family Medicine North",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sutherlin, OR

Sources for this page

Verify at the official NPI Registry.