1528066859 NPI number — PEDIATRIC ASSOCIATES OF THE NORTHWEST, PC

Table of content: (NPI 1528066859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528066859 NPI number — PEDIATRIC ASSOCIATES OF THE NORTHWEST, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC ASSOCIATES OF THE NORTHWEST, 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:
1528066859
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2701 NW VAUGHN ST
Provider Second Line Business Mailing Address:
SUITE 360
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-227-0671
Provider Business Mailing Address Fax Number:
503-227-0676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14795 SW MURRAY SCHOOLS DR.
Provider Second Line Business Practice Location Address:
SUITE 121
Provider Business Practice Location Address City Name:
BEAVERTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-673-1071
Provider Business Practice Location Address Fax Number:
503-227-4589
Provider Enumeration Date:
07/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COLBURN
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
503-419-4940

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  2000742 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 646412 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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