Provider Demographics
NPI:1679705289
Name:COLUMBIA SANDS MEDICAL SPECIALITIES, LLC
Entity type:Organization
Organization Name:COLUMBIA SANDS MEDICAL SPECIALITIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-408-0436
Mailing Address - Street 1:1245 NW 4TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1680
Mailing Address - Country:US
Mailing Address - Phone:541-526-6626
Mailing Address - Fax:
Practice Address - Street 1:1245 NW 4TH ST STE 201
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1680
Practice Address - Country:US
Practice Address - Phone:541-526-6626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty