1114558368 NPI number — OREGON PEDIATRICS-OREGON CITY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114558368 NPI number — OREGON PEDIATRICS-OREGON CITY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OREGON PEDIATRICS-OREGON CITY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114558368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8645 SE SUNNYBROOK BLVD # 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLACKAMAS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97015-6841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-659-1694
Provider Business Mailing Address Fax Number:
503-659-8984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 DIVISION ST STE 80
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-1572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-659-1694
Provider Business Practice Location Address Fax Number:
503-659-8984
Provider Enumeration Date:
01/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
RUPA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
503-659-1694

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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