NPIMap

Organization Active NPI

Evergreen Family Medicine, PC

  • Family Medicine Physician
  • Roseburg, OR
National Provider Identifier
1417929050
Registry record updated Jul 22, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
EVERGREEN FAMILY MEDICINE, PC
Practice address
2570 NW Edenbower Blvd Ste 100
Roseburg, OR 97471-6214
Phone
(541) 229-3301
Fax
(541) 677-7462
NPI assigned
Feb 7, 2006
Last updated
Jul 22, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 22, 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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine Physician 207P00000X
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

2570 NW Edenbower Blvd Ste 100
Roseburg, OR 97471-6214

Mailing address

2570 NW Edenbower Blvd
Ste 100
Roseburg, OR 97470-6214
Phone (541) 229-3301

Other practice location 1

1937 W Harvard Ave
Roseburg, OR 97471-2720
Phone (541) 677-7200

Other identifiers 2

IdentifierTypeStateIssuer
000116MedicaidOR
CN5472OtherORGROUP RAILROAD

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040330000219 OR Part B Supplier - Clinic/Group Practice 3870485139 Receives reassigned benefits from 1 practitioner
1 other NPI on this enrollment
Practice locations: Roseburg, OR

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/1334/brand/1/csg/42/fhir/r4

Practitioners & affiliated clinicians

Practitioners 73

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 73

NPI Registry JSON

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

{
    "created_epoch": "1139270400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1753142400000",
    "number": "1417929050",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2570 NW EDENBOWER BLVD",
            "address_2": "STE 100",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974706214",
            "telephone_number": "541-229-3301",
            "fax_number": "541-677-7462"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2570 NW EDENBOWER BLVD STE 100",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974716214",
            "telephone_number": "541-229-3301",
            "fax_number": "541-677-7462"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1937 W Harvard Ave",
            "address_purpose": "LOCATION",
            "city": "Roseburg",
            "state": "OR",
            "postal_code": "974712720",
            "country_code": "US",
            "telephone_number": "541-677-7200",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "EVERGREEN FAMILY MEDICINE, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-02-07",
        "last_updated": "2025-07-22",
        "certification_date": "2025-07-22",
        "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": "",
            "desc": "Emergency Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000116",
            "state": "OR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP RAILROAD",
            "identifier": "CN5472",
            "state": "OR"
        }
    ],
    "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 22, 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.