Active NPI
Centennial Medical Group, Inc
- Urology Physician
- Roseburg, OR
National Provider Identifier
1225207152
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Urology Physician
- License
- 497634-93
- Legal business name
- CENTENNIAL MEDICAL GROUP, INC
- Practice address
- 2460 NW Stewart Parkway,
Suite 100
Roseburg, OR 97471 - Phone
- (541) 677-6141
- Fax
- (541) 677-6143
- NPI assigned
- Feb 25, 2008
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Jason Gray, MD
- Title
- President
- Phone
- (541) 677-2494
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Urology Physician | 208800000X | 497634-93 | OR | Primary |
Addresses
Primary practice location
2460 NW Stewart Parkway,
Suite 100
Roseburg, OR 97471
Mailing address
P.O. Box 910
Roseburg, OR 97470
Phone (541) 677-6141
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 171678 | Medicaid | OR |
Other names 1
- DBA Roseburg Urology
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in OR
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031111000222 | OR | Part B Supplier - Clinic/Group Practice | 9234047697 |
Receives reassigned benefits from 14 practitioners 8 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Pendleton, OR; Roseburg, OR |
Other NPIs on the same Medicare enrollment 6
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
-
- Cardiovascular Disease Physician
- Roseburg, OR
- NPI 1033365135
O20031111000222
National Provider Directory
National Provider DirectoryNPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1203897600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1333497600000",
"number": "1225207152",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "P.O. BOX 910",
"city": "ROSEBURG",
"state": "OR",
"postal_code": "97470",
"telephone_number": "541-677-6141",
"fax_number": "541-677-6143"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2460 NW STEWART PARKWAY,",
"address_2": "SUITE 100",
"city": "ROSEBURG",
"state": "OR",
"postal_code": "97471",
"telephone_number": "541-677-6141",
"fax_number": "541-677-6143"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "CENTENNIAL MEDICAL GROUP, INC",
"organizational_subpart": "NO",
"enumeration_date": "2008-02-25",
"last_updated": "2012-04-04",
"status": "A",
"authorized_official_last_name": "GRAY",
"authorized_official_first_name": "JASON",
"authorized_official_title_or_position": "PRESIDENT",
"authorized_official_telephone_number": "541-677-2494",
"authorized_official_credential": "MD"
},
"taxonomies": [
{
"code": "208800000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Urology",
"state": "OR",
"license": "497634-93",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "171678",
"state": "OR"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "DBA Roseburg Urology",
"code": "3",
"type": "Doing Business As"
}
]
}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 Apr 4, 2012; 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.