NPIMap

Organization Active NPI

Mountain West Derm - Blackhart PLLC

  • Dermatology Physician
  • Roseburg, OR
National Provider Identifier
1891467577
Registry record updated Oct 4, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
MOUNTAIN WEST DERM - BLACKHART PLLC
Practice address
341 NW Medical Loop Ste 110
Roseburg, OR 97471-5546
Phone
(541) 440-2165
Fax
(541) 440-8932
NPI assigned
Oct 1, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 4, 2021

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

Authorized official

Name
Jeffrey B Shackelton, MDNPI 1699902726
Title
Owner
Phone
(775) 283-4086

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

341 NW Medical Loop Ste 110
Roseburg, OR 97471-5546

Mailing address

341 NW Medical Loop Ste 110
Roseburg, OR 97471-5546

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20171219002516 OR Part B Supplier - Clinic/Group Practice 1153609813 Receives reassigned benefits from 39 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Tigard, OR; Roseburg, OR; Redmond, OR; Bend, OR; Prineville, OR; Klamath Falls, OR; Lake Oswego, OR; Ashland, OR

Other NPIs on the same Medicare enrollment 2

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

National Provider Directory

National Provider Directory

Locations

2747 NE Conners Ave
Bend, OR 97701
Phone (541) 322-1980

Practitioners & affiliated clinicians

Practitioners 42

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

View all 42

NPI Registry JSON

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

{
    "created_epoch": "1633046400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1633305600000",
    "number": "1891467577",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "341 NW MEDICAL LOOP STE 110",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974715546"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "341 NW MEDICAL LOOP STE 110",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974715546",
            "telephone_number": "541-440-2165",
            "fax_number": "541-440-8932"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN WEST DERM - BLACKHART PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-10-01",
        "last_updated": "2021-10-04",
        "certification_date": "2021-10-04",
        "status": "A",
        "authorized_official_last_name": "SHACKELTON",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "775-283-4086",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "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 Oct 4, 2021; 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.