Pony Creek Annex, LLC

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

Legal business name

PONY CREEK ANNEX, LLC

Doing business as

Bay Eye Surgery Center

Practice address

2075 Public Square Court
North Bend, OR 97459-1270

Phone

(541) 297-9551

NPI assigned

Jun 9, 2021

Last updated

Jun 9, 2021By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Jane Gilbert, MDNPI 1356342950

Title

Medical Director

Phone

(541) 297-9551

Specialties & licenses 1

Addresses

Other names 1

• Bay Eye Surgery Center Doing business as

Medicare fee-for-service enrollment

Enrolled in OR

Enrollment records 1

Listed as

Pony Creek Annex LLC Dba Bay Eye Surgery CenterCCN 38C0001119

Medicare certification status

ActiveFrom the Provider of Services file

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

CLIA laboratory certificates

Practitioners 2

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.

• Jane Gilbert, M.D.

  • Ophthalmology Physician
  • North Bend, OR
  • NPI 1356342950
  NPD Authorized official
• Debra A. Graham, M.D.

  • Ophthalmology Physician
  • North Bend, OR
  • NPI 1548261381
  NPD

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

{
    "created_epoch": "1623196800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1623196800000",
    "number": "1538736459",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3585 BROADWAY AVE",
            "city": "NORTH BEND",
            "state": "OR",
            "postal_code": "974591251",
            "telephone_number": "541-756-2584"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2075 PUBLIC SQUARE COURT",
            "city": "NORTH BEND",
            "state": "OR",
            "postal_code": "974591270",
            "telephone_number": "541-297-9551"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PONY CREEK ANNEX, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-06-09",
        "last_updated": "2021-06-09",
        "certification_date": "2021-05-21",
        "status": "A",
        "authorized_official_last_name": "GILBERT",
        "authorized_official_first_name": "JANE",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "541-297-9551",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Bay Eye Surgery Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Gary Pickett, HIS
• Katie Pierson
• Melissa A Piper, LPC
• Joseph Ryan Plouff, PARAMEDIC
• Carla Rae Poltycia
• Chris Poor
• Connie Prince
• Hammad Qadir
• R Scott Roberts DDS PC
• Cynthia Ramirez

• Ambulatory Surgical Clinic/Center in North Bend, OR
• Providers in North Bend, OR by specialty
• Ambulatory Surgical Clinic/Center in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.