1205838877 NPI number — DR. GILBERT C CHILD MD

Table of content: DR. GILBERT C CHILD MD (NPI 1205838877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205838877 NPI number — DR. GILBERT C CHILD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHILD
Provider First Name:
GILBERT
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1205838877
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6420 SW MACADAM AVE
Provider Second Line Business Mailing Address:
SUITE 216
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97239-3507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-244-8601
Provider Business Mailing Address Fax Number:
503-244-8738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9155 SW BARNES RD
Provider Second Line Business Practice Location Address:
336
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225-6625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-292-0848
Provider Business Practice Location Address Fax Number:
503-296-0635
Provider Enumeration Date:
08/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD11128 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 066159 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180015176 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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