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EVERGREEN FAMILY MEDICINE, PC
NPI 1417929050
Family Medicine in Roseburg, OR

Active since February 07, 2006CLIA 38D1026493 · Waiver
2570 NW EDENBOWER BLVD STE 100, ROSEBURG, OR 97471(541) 229-3301(541) 677-7462 Get Directions Write a Review

NPPES record last updated: July 22, 2025. Verified against the NPPES registry weekly; last sync: October 18, 2026.

About Evergreen Family Medicine, Pc NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

EVERGREEN FAMILY MEDICINE, PC (NPI 1417929050) is a healthcare organization registered as a family medicine in Roseburg, Oregon and active in the NPI registry since February 2006. The organization holds a CLIA Waiver certificate valid through June 6, 2028, maintains a secondary practice location in Roseburg, and lists Kimberly Tyree, Coo, as its authorized official.

NPPES Registry Identity

NPI1417929050
Entity TypeOrganization
Primary Taxonomy207Q00000X
Legal Business NameEVERGREEN FAMILY MEDICINE, PC
Location Address2570 NW EDENBOWER BLVD STE 100Roseburg, OR 97471-6214
Mailing Address2570 Nw Edenbower Blvd, Ste 100Roseburg, OR 97470-6214 · (541) 229-3301 · Fax (541) 677-7462
Phone(541) 229-3301
Fax(541) 677-7462
Organization SubpartNo
Authorized OfficialKimberly TyreeCoo · (541) 229-3332
Enumeration DateFebruary 7, 2006
Last NPPES UpdateJuly 22, 2025
NPPES CertifiedJuly 22, 2025
✔ NPI 1417929050 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 2

★ Primary SpecialtyFamily MedicineAllopathic & Osteopathic Physicians
Taxonomy Code207Q00000X
Definition
Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity.
Also ListedEmergency MedicineTaxonomy 207P00000X
2570 NW EDENBOWER BLVD STE 100, Roseburg, OR 97471
Open in Google Maps ↗

Secondary Practice Location 1

Location 11937 W Harvard AveRoseburg, OR 97471-2720 · Phone (541) 677-7200

Other Identifiers 2

Medicaid000116OR
OtherCN5472OR · Group Railroad

Group Practice 1

Group TaxonomyThis provider is a business group of one or more individual practitioners, who practice with different areas of specialization.193200000X MULTI-SPECIALTY GROUP

Medicare Participation & PECOS CMS

Medicare enrollment and the clinicians who bill Medicare through this organization, from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Evergreen Family Medicine, Pc is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Clinicians Billing Medicare Through This Organization

Medicare enrollment records show 1 clinician reassigns Medicare billing to Evergreen Family Medicine, PC, which bills Medicare for the services this clinician delivers.

Clinician (1)

Derek Wiseman, MD
Family Practice
NPI 1952988222
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare1.8 mi

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

CLIA Laboratory Certificates CMS CLIA 2

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 38D1026493

Evergreen Family Medicine Womens Health · Roseburg, OR
Active · expires Jun 6, 2028
CLIA Number38D1026493
Laboratory TypePhysician Office
Certificate Effective DateJune 7, 2026
Certificate Expiration DateJune 6, 2028
Laboratory DirectorMary E. Powell
Laboratory Phone(541) 677-7200
Laboratory LocationEvergreen Family Medicine Womens Health1937 W Harvard Avenue, Roseburg, OR 97471
CLIA data matches this NPI record on: Address Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Certificate of Waiver 38D2120598

Evergreen Family Medicine · Roseburg, OR
Expired · Oct 18, 2026
CLIA Number38D2120598
Laboratory TypeRural Health Clinic
Certificate Effective DateOctober 19, 2024
Certificate Expiration DateOctober 18, 2026
Laboratory DirectorTimothy Powell MD
Laboratory Phone(541) 229-3332
Laboratory LocationEvergreen Family Medicine1937 W Harvard Ave Attn Kim Tyree, Roseburg, OR 97471
CLIA data matches this NPI record on: Address Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Evergreen Family Medicine, PC's NPI number?

The NPI number for Evergreen Family Medicine, PC is 1417929050. It was assigned to this organization in the NPPES registry on February 7, 2006.

Where is Evergreen Family Medicine, PC located?

Evergreen Family Medicine, PC is located at 2570 NW Edenbower Blvd Ste 100, Roseburg, OR 97471. The listed phone number is (541) 229-3301.

What is Evergreen Family Medicine, PC's specialty?

The primary specialty registered for this NPI is Family Medicine with taxonomy code 207Q00000X.

Is Evergreen Family Medicine, PC enrolled in Medicare?

Yes. Evergreen Family Medicine, PC is registered in the Medicare PECOS enrollment system.

How many clinicians bill Medicare through Evergreen Family Medicine, PC?

According to the CMS Revalidation Reassignment List (October 2026 release), 1 clinician (Family Practice) reassigns their Medicare billing to Evergreen Family Medicine, PC. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Does Evergreen Family Medicine, PC hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 38D1026493) is associated with this NPI, valid through June 6, 2028. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Evergreen Family Medicine, PC was last updated on July 22, 2025. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 15 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.