NPIMap

Organization Active NPI

Centennial Medical Group East, LLC

  • Rural Health Clinic/Center
  • Roseburg, OR
National Provider Identifier
1821366071
Registry record updated Feb 6, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CENTENNIAL MEDICAL GROUP EAST, LLC
Practice address
2570 NW Edenbower Blvd
Roseburg, OR 97471-6214
Phone
(541) 677-7200
Fax
(541) 229-3309
NPI assigned
Dec 2, 2011
Organization subpart
Yes
Parent organization
CENTENNIAL MEDICAL GROUP, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 6, 2013

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

Authorized official

Name
Dr. Jason Gray, MD
Title
President
Phone
(541) 677-2494

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

2570 NW Edenbower Blvd
Roseburg, OR 97471-6214

Mailing address

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

Other names 1

  • Evergreen Family Medicine 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
O20120328000411 OR Part A Provider - Rural Health Clinic 9234397878 Practice locations: Roseburg, OR

Rural health clinic certification: CCN 383880

Legal name
CENTENNIAL MEDICAL GROUP EAST LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 18, 2011
Last certification
Sep 19, 2024
Ownership / control type
2B
Organization structure
LLCNon-profit
Enrollment address
2570 NW Edenbower Blvd
Suite 100
Roseburg, OR 97471-6214

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 GRP East5 organizations share this tax ID, including this one
Part of
Centennial Medical Group

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

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

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

Ownership & related parties

All disclosed owners & managing parties 2

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 Created for acquisition, Non-profit 5% Or Greater Direct Ownership Interest Oct 1, 2010 100%

Owners & managing parties with NPI records 1

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 63

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 63

NPI Registry JSON

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

{
    "created_epoch": "1322784000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1360108800000",
    "number": "1821366071",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2570 NW EDENBOWER BLVD",
            "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": "2570 NW EDENBOWER BLVD",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974716214",
            "telephone_number": "541-677-7200",
            "fax_number": "541-229-3309"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTENNIAL MEDICAL GROUP EAST, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTENNIAL MEDICAL GROUP, INC.",
        "enumeration_date": "2011-12-02",
        "last_updated": "2013-02-06",
        "status": "A",
        "authorized_official_last_name": "GRAY",
        "authorized_official_first_name": "JASON",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "541-677-2494",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Roseburg, OR

Sources for this page

Verify at the official NPI Registry.