Provider Demographics
NPI:1871919639
Name:H. THOMAS HARVEY
Entity type:Organization
Organization Name:H. THOMAS HARVEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-362-6304
Mailing Address - Street 1:1155 MISSION ST SE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6228
Mailing Address - Country:US
Mailing Address - Phone:503-362-6304
Mailing Address - Fax:
Practice Address - Street 1:2995 RYAN DR SE
Practice Address - Street 2:SUITE 200
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-5157
Practice Address - Country:US
Practice Address - Phone:503-371-7701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WVP MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11557261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR041947Medicaid
OR041947Medicaid
ORC92827Medicare UPIN