NPIMap

Organization Active NPI

Centennial Medical Group East, LLC

  • Rural Health Clinic/Center
  • Roseburg, OR
National Provider Identifier
1235688805
Registry record updated May 1, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
38-3896 Issued in OR
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
Sep 23, 2016
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
Kim Tyree
Title
Coo
Phone
(541) 229-3332

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 38-3896 OR Primary
Family Medicine Physician 207Q00000X MD12182 OR

Addresses

Primary practice location

1937 W Harvard Ave
Roseburg, OR 97471-2720

Mailing address

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

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
O20170131002098 OR Part A Provider - Rural Health Clinic 9234397878 Practice locations: Roseburg, OR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1235688805. Details of each certification follow.

Rural health clinic certification: CCN 383896

Legal name
CENTENNIAL MEDICAL GROUP EAST LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 14, 2018
Last certification
Sep 17, 2024
Ownership / control type
2B
Organization structure
LLCNon-profit
Incorporated
Sep 2, 2010 in OR
Enrollment address
1937 W Harvard Ave
Roseburg, OR 97471-2720

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
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.

Member of 1

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

Locations

1937 W Harvard Ave
Roseburg, OR 97471
Phone (541) 677-7200

2510 NW Medical Park Dr
Roseburg, OR 97471
Phone (541) 440-9128

Ownership & related parties

All disclosed owners & managing parties 3

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 Corporate OfficerPresident Sep 2, 2010
Operational/Managerial Control Sep 2, 2010
Kimberly K Tyree Individual Corporate OfficerCoo Apr 13, 2015
Centennial Medical Group Inc Organization, Roseburg, OR Non-profit 5% Or Greater Direct Ownership Interest Nov 1, 2011 100%

Owners & managing parties with NPI records 2

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 18

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 18

NPI Registry JSON

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

{
    "created_epoch": "1474588800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1588291200000",
    "number": "1235688805",
    "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": "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": "2016-09-23",
        "last_updated": "2020-05-01",
        "certification_date": "2020-05-01",
        "status": "A",
        "authorized_official_last_name": "TYREE",
        "authorized_official_first_name": "KIM",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "541-229-3332"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "OR",
            "license": "38-3896",
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OR",
            "license": "MD12182",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Roseburg, OR

Sources for this page

Verify at the official NPI Registry.