NPIMap

Organization Active NPI

WVP Medical Group, LLC

  • Primary Care Clinic/Center
  • Keizer, OR
National Provider Identifier
1750684767
Registry record updated Apr 17, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
WVP MEDICAL GROUP, LLC
Practice address
5100 River Rd N
Keizer, OR 97303-5371
Phone
(503) 393-2533
Fax
(503) 393-5978
NPI assigned
Dec 13, 2010
Last updated
Apr 17, 2018By the provider in NPPES
Organization subpart
Yes
Parent organization
MID VALLEY IPA (WVP HEALTH AUTHORITY)As reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 17, 2018

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

Authorized official

Name
Mr. Dean Andretta
Title
Cfo
Phone
(503) 371-7701

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X NU Primary

Addresses

Primary practice location

5100 River Rd N
Keizer, OR 97303-5371

Mailing address

2995 Ryan Dr SE Ste 200
Salem, OR 97301-5157
Phone (503) 371-7701

Other identifiers 1

IdentifierTypeStateIssuer
288533MedicaidOR

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100209000818 OR Part B Supplier - Clinic/Group Practice 4486627965 Receives reassigned benefits from 3 practitioners
8 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Salem, OR

Other NPIs on the same Medicare enrollment 8

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

National Provider Directory

National Provider Directory

NPI Registry JSON

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

{
    "created_epoch": "1292198400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1523923200000",
    "number": "1750684767",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2995 RYAN DR SE STE 200",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973015157",
            "telephone_number": "503-371-7701"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5100 RIVER RD N",
            "city": "KEIZER",
            "state": "OR",
            "postal_code": "973035371",
            "telephone_number": "503-393-2533",
            "fax_number": "503-393-5978"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WVP MEDICAL GROUP, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MID VALLEY IPA (WVP HEALTH AUTHORITY)",
        "enumeration_date": "2010-12-13",
        "last_updated": "2018-04-17",
        "status": "A",
        "authorized_official_last_name": "ANDRETTA",
        "authorized_official_first_name": "DEAN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "503-371-7701",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "288533",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Keizer, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 17, 2018; 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.