NPIMap

Organization Active NPI

Centennial Medical Group East, LLC

Doing business as Evergreen Family Medicine South

  • Rural Health Clinic/Center
  • Myrtle Creek, OR
National Provider Identifier
1699103598
Registry record updated Nov 22, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CENTENNIAL MEDICAL GROUP EAST, LLC
Doing business as
Evergreen Family Medicine South
Practice address
145 NE Broadway St
Myrtle Creek, OR 97457-9039
Phone
(541) 863-3146
Fax
(541) 863-3226
NPI assigned
Oct 31, 2013
Last updated
Nov 22, 2016By the provider in NPPES
Organization subpart
Yes
Parent organization
CENTENNIAL MEDICAL GROUP DBA EVERGREEN FAMILY MEDICINE SOUTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 22, 2016

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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X OR Primary
Family Medicine Physician 207Q00000X 71216890 OR
Family Medicine Physician 207Q00000X OR

Addresses

Primary practice location

145 NE Broadway St
Myrtle Creek, OR 97457-9039

Mailing address

2801 NW Mercy Dr
Suite 340
Roseburg, OR 97471-2348
Phone (541) 677-2494

Other names 1

  • Evergreen Family Medicine South 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
O20140407001744 OR Part A Provider - Rural Health Clinic 9234397878 Practice locations: Myrtle Creek, OR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1699103598. Details of each certification follow.

Rural health clinic certification: CCN 383891

Legal name
CENTENNIAL MEDICAL GROUP EAST LLC
Doing business as
EVERGREEN FAMILY MEDICINE SOUTH
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 9, 2015
Last certification
Jun 15, 2023
Ownership / control type
2B
Organization structure
LLCNon-profit
Enrollment address
145 NE Broadway St
Myrtle Creek, OR 97457-9039

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
38D0627175CMG East Dba Evergreen Family Medicine South145 NE Broadway, Myrtle Creek, OR 97457Provider-performed microscopyDec 31, 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.

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
Kimberly K Tyree Individual Corporate OfficerChief Operations Officer Apr 11, 2015
Operational/Managerial ControlChief Operations Officer Apr 11, 2015
Centennial Medical Group Inc Organization, Roseburg, OR Non-profit 5% Or Greater Direct Ownership Interest Mar 1, 2014 100%
Jason F Gray Individual Corporate OfficerPresident Apr 15, 2011

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 17

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 17

NPI Registry JSON

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

{
    "created_epoch": "1383177600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1479772800000",
    "number": "1699103598",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2801 NW MERCY DR",
            "address_2": "SUITE 340",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974712348",
            "telephone_number": "541-677-2494",
            "fax_number": "541-677-2294"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "145 NE BROADWAY ST",
            "city": "MYRTLE CREEK",
            "state": "OR",
            "postal_code": "974579039",
            "telephone_number": "541-863-3146",
            "fax_number": "541-863-3226"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTENNIAL MEDICAL GROUP EAST, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTENNIAL MEDICAL GROUP DBA EVERGREEN FAMILY MEDICINE SOUTH",
        "enumeration_date": "2013-10-31",
        "last_updated": "2016-11-22",
        "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": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OR",
            "license": "71216890",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OR",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Family Medicine South",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Myrtle Creek, OR

Sources for this page

Verify at the official NPI Registry.