| Dba-pine Eagle Clinic | |
|
218 North Pine Street Halfway OR 97834 | |
| (541) 742-5023 | |
| (541) 742-7210 |
| Full Name | Dba-pine Eagle Clinic |
|---|---|
| Speciality | Clinic/Center |
| Location | 218 North Pine Street, Halfway, Oregon |
| Authorized Official Name and Position | Terra Jean Lewis (ADMINISTRATOR) |
| Authorized Official Contact | 5417425024 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Dba-pine Eagle Clinic P.o. Box 647 Halfway OR 97834 Ph: (541) 742-5023 | Dba-pine Eagle Clinic 218 North Pine Street Halfway OR 97834 Ph: (541) 742-5023 |
| NPI Number | 1922102128 |
|---|---|
| Provider Enumeration Date | 09/11/2006 |
| Last Update Date | 06/17/2020 |
| Certification Date | 06/17/2020 |
| Medicare PECOS PAC ID | 8729075346 |
|---|---|
| Medicare Enrollment ID | O20040427000610 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1922102128 | NPI | - | NPPES |
| R139059 | Other | OR | MEDICARE B |
| 025069 | Medicaid | OR | |
| 009919000 | Other | OR | BLUE CROSS BLUE SHIELD |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QR1300X | Clinic/center - Rural Health | 383869 (Oregon) | Primary |
| Provider Name | Jesse D Smithson |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1427046820 PECOS PAC ID: 4486566148 Enrollment ID: I20031205000091 |
| Provider Name | Kathryn L Grace |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1467575639 PECOS PAC ID: 4183675952 Enrollment ID: I20120817000205 |
| Provider Name | Dean N Defrees |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1073924361 PECOS PAC ID: 9133446073 Enrollment ID: I20170828001258 |
| Provider Name | Korey V Ham |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1285153932 PECOS PAC ID: 7810241767 Enrollment ID: I20181113002741 |