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EVERGREEN FAMILY MEDICINE SOUTH
NPI 1699103598
Clinic/Center - Rural Health in Myrtle Creek, OR

Active since October 31, 2013CLIA 38D0627175 · Microscopy
145 NE BROADWAY ST, MYRTLE CREEK, OR 97457(541) 863-3146(541) 863-3226 Get Directions Write a Review

NPPES record last updated: November 22, 2016. Verified against the NPPES registry weekly; last sync: October 18, 2026.

About Evergreen Family Medicine South NPPES

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

EVERGREEN FAMILY MEDICINE SOUTH (NPI 1699103598) is a healthcare organization registered as a rural health in Myrtle Creek, Oregon and active in the NPI registry since October 2013. The organization holds a CLIA Microscopy certificate valid through December 31, 2027 and lists Kim Tyree, Coo, as its authorized official.

NPPES Registry Identity

NPI1699103598
Entity TypeOrganization
Primary Taxonomy261QR1300X
Legal Business NameCENTENNIAL MEDICAL GROUP EAST, LLC
Location Address145 NE BROADWAY STMyrtle Creek, OR 97457-9039
Mailing Address2801 Nw Mercy Dr, Suite 340Roseburg, OR 97471-2348 · (541) 677-2494 · Fax (541) 677-2294
Phone(541) 863-3146
Fax(541) 863-3226
Organization SubpartYesParent: Centennial Medical Group Dba Evergreen Family Medicine South
Authorized OfficialKim TyreeCoo · (541) 229-3332
Enumeration DateOctober 31, 2013
Last NPPES UpdateNovember 22, 2016
✔ NPI 1699103598 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 2

★ Primary SpecialtyClinic/Center · Rural HealthAmbulatory Health Care Facilities
Taxonomy Code261QR1300X
Also ListedFamily MedicineTaxonomy 207Q00000X · License 71216890 (OR)
145 NE BROADWAY ST, Myrtle Creek, OR 97457
Open in Google Maps ↗

Other Names 1

Doing Business AsEvergreen Family Medicine South

Other Identifiers 1

Medicare OSCAR/certification383891OR

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

Accepted Insurance

The full list of accepted plans is on the Insurance tab. Issuers include Moda Health Plan, Inc., Providence Health Plan.Insurance ›

Medicare Participation & PECOS CMS

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

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

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

Medicare Revalidation Due Date

Revalidation due by January 31, 2027

Medicare-enrolled providers and suppliers confirm their enrollment information with CMS on a set cycle, every 5 years for most and every 3 years for medical equipment suppliers. CMS sets the due date for each enrollment.

StateEnrollment IDDue date
StateOregonEnrollment IDO20120228000510Non-DME Part B · Clinic/Group PracticeDue dateJanuary 31, 2027
Source: CMS Revalidation Due Date List, October 2026 release.

Clinicians Billing Medicare Through This Organization

61

Medicare enrollment records show 61 clinicians reassign Medicare billing to Evergreen Family Medicine South, which bills Medicare for the services they deliver. Of these, 3 practice at this address. Listed here are the 20 practicing nearest to this location.

Clinicians by Medicare Specialty 12

Family Practice26
Nurse Practitioner10
Mental Health Counselor7
Certified Nurse Midwife (CNM)3
Internal Medicine3
Obstetrics/Gynecology3
Endocrinology2
Hospitalist2
4 other specialties5

Nearest to this location (20)

See all 61
Kimberlly Stevens, FNP
Nurse Practitioner
NPI 1851828511
145 NE BROADWAY ST
Myrtle Creek, OR 97457
(541) 677-7200
✔ PECOS✔ Accepts MedicareSame address
Jacqueline Johnson, D.O.
Family Practice
NPI 1083814099
145 NE BROADWAY ST
Myrtle Creek, OR 97457
(541) 677-7200
✔ PECOS✔ Accepts MedicareSame address
Kristina Skinner, FNP
Nurse Practitioner
NPI 1255744611
145 NE BROADWAY ST
Myrtle Creek, OR 97457
(541) 863-3146
✔ PECOS✔ Accepts MedicareSame address
Susan Ellis, PMHNP
Nurse Practitioner
NPI 1750706800
621 W MADRONE ST
Roseburg, OR 97470
(541) 492-4550
✔ PECOS✔ Accepts Medicare13 mi
Judy Black, M.D.
Pediatric Medicine
NPI 1770786667
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS14 mi
Natalie Groshong, MD
Internal Medicine
NPI 1952042939
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare14 mi
Vishal Kottapalli, DO
Family Practice
NPI 1053044610
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare14 mi
Dana Martin, CNM
Certified Nurse Midwife (CNM)
NPI 1124907472
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare14 mi
Brandi Myers, BS
Mental Health Counselor
NPI 1770165631
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS14 mi
Humberto Villalvazo, MD
Family Practice
NPI 1902994551
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare14 mi
Kolby Wade, CNM
Certified Nurse Midwife (CNM)
NPI 1407517931
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare14 mi
Alyssa Emo, DO
Obstetrics/Gynecology
NPI 1811343155
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare14 mi
Ryan Melton, LPC
Mental Health Counselor
NPI 1851590400
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare14 mi
Emmanuel Okenye
Internal Medicine
NPI 1346777950
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare14 mi
Elizabeth Oler, M.D.
Obstetrics/Gynecology
NPI 1760894760
1937 W HARVARD AVE
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare14 mi
Joseph Black, M D
Gastroenterology
NPI 1578524377
2550 NW EDENBOWER BLVD SUITE 100
Roseburg, OR 97471
(541) 580-5328
✔ PECOS✔ Accepts Medicare15 mi
Tierney Sathianathan, DO
Emergency Medicine
NPI 1548756257
2570 NW EDENBOWER BLVD STE 100
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare15 mi
Steven Burns, M.D.
General Practice
NPI 1568572725
2570 NW EDENBOWER BLVD. STE 100
Roseburg, OR 97471
(541) 957-1111
✔ PECOS15 mi
Patrick Clyde, MD
Endocrinology
NPI 1538254941
2570 NW EDENBOWER BLVD. SUITE 100
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare15 mi
Jarrod Cullan, MD
Hospitalist
NPI 1912438136
2570 NW EDENBOWER BLVD STE 100
Roseburg, OR 97471
(541) 677-7200
✔ PECOS✔ Accepts Medicare15 mi
See all 61 clinicians

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

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 for Provider-Performed Microscopy Procedures (PPMP) 38D0627175

Cmg East Dba Evergreen Family Medicine South · Myrtle Creek, OR
Active · expires Dec 31, 2027
CLIA Number38D0627175
Laboratory TypePhysician Office
Certificate Effective DateJanuary 1, 2026
Certificate Expiration DateDecember 31, 2027
Laboratory DirectorTimothy J Powell MD
Laboratory Phone(541) 863-3146
Laboratory LocationCmg East Dba Evergreen Family Medicine South145 NE Broadway, Myrtle Creek, OR 97457
CLIA data matches this NPI record on: Address Name Phone
This certificate is issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform 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 Centennial Medical Group East, LLC's NPI number?

The NPI number for Centennial Medical Group East, LLC is 1699103598. It was assigned to this organization in the NPPES registry on October 31, 2013. The provider is doing business as Evergreen Family Medicine South.

Where is Centennial Medical Group East, LLC located?

Centennial Medical Group East, LLC is located at 145 NE Broadway St, Myrtle Creek, OR 97457. The listed phone number is (541) 863-3146.

What is Centennial Medical Group East, LLC's specialty?

The primary specialty registered for this NPI is Clinic/Center, specializing in Rural Health, with taxonomy code 261QR1300X.

Is Centennial Medical Group East, LLC enrolled in Medicare?

Yes. Centennial Medical Group East, LLC is registered in the Medicare PECOS enrollment system.

When is Centennial Medical Group East, LLC's Medicare revalidation due?

According to the CMS Revalidation Due Date List (October 2026 release), the Medicare Non-DME Part B enrollment for this organization (Oregon, Clinic/Group Practice) is due for revalidation by January 31, 2027. Medicare providers and suppliers revalidate their enrollment every 5 years, and medical equipment suppliers every 3 years. Confirm current requirements with your Medicare Administrative Contractor.

How many clinicians bill Medicare through Centennial Medical Group East, LLC?

According to the CMS Revalidation Reassignment List (October 2026 release), 61 clinicians in 12 Medicare specialties reassign their Medicare billing to Centennial Medical Group East, LLC. 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. The largest specialties are Family Practice (26), Nurse Practitioner (10) and Mental Health Counselor (7). Of these, 3 practice at this address. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Does Centennial Medical Group East, LLC hold a CLIA laboratory certificate?

Yes. A Certificate for Provider-Performed Microscopy Procedures (PPMP) (number 38D0627175) is associated with this NPI, valid through December 31, 2027. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

What insurance does Centennial Medical Group East, LLC accept?

Health plans from Moda Health Plan, Inc. and Providence Health Plan list Centennial Medical Group East, LLC as in-network in at least one marketplace plan. Coverage varies by plan and year; verify with the insurer or the provider before a visit.

When was this NPI record last updated?

The NPPES record for Centennial Medical Group East, LLC was last updated on November 22, 2016. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 9 years 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.