| Wvp Medical Group, Llc | |
|
2485 12th St Se Salem OR 97302-2151 | |
| (503) 363-8047 | |
| (503) 363-6571 |
| Full Name | Wvp Medical Group, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 2485 12th St Se, Salem, Oregon |
| Authorized Official Name and Position | Dean G. Andretta (CFO) |
| Authorized Official Contact | 5033717701 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Wvp Medical Group, Llc 2995 Ryan Dr Se Ste. 200 Salem OR 97301-5157 Ph: (503) 371-7701 | Wvp Medical Group, Llc 2485 12th St Se Salem OR 97302-2151 Ph: (503) 363-8047 |
| NPI Number | 1124352877 |
|---|---|
| Provider Enumeration Date | 09/29/2009 |
| Last Update Date | 04/19/2018 |
| Medicare PECOS PAC ID | 4486627965 |
|---|---|
| Medicare Enrollment ID | O20100209000818 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1124352877 | NPI | - | NPPES |
| R151720 | Other | OR | PTAN |
| 288533 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207QB0002X | Family Medicine - Obesity Medicine | (* (Not Available)) | Secondary |
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| Provider Name | James Tomasevich |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1013099522 PECOS PAC ID: 3476771544 Enrollment ID: I20180906001193 |
| Provider Name | Robert W Nielsen |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1902279334 PECOS PAC ID: 0840534558 Enrollment ID: I20181206003451 |
| Provider Name | Marianne Petersen |
|---|---|
| Provider Type | Practitioner - Registered Dietitian Or Nutrition Professional |
| Provider Identifiers | NPI Number: 1679247795 PECOS PAC ID: 1254707664 Enrollment ID: I20221026000105 |
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