Provider Demographics
NPI:1134799489
Name:SMALL TOWN PEDIATRICS LLC
Entity type:Organization
Organization Name:SMALL TOWN PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HAMBLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:971-304-9855
Mailing Address - Street 1:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-0106
Mailing Address - Country:US
Mailing Address - Phone:503-400-3852
Mailing Address - Fax:503-334-2268
Practice Address - Street 1:607 WELCH ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1946
Practice Address - Country:US
Practice Address - Phone:503-400-3852
Practice Address - Fax:503-334-2268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500675213Medicaid