1023032372 NPI number — NORTHWEST PRIMARY CARE GROUP PC

Table of content: (NPI 1023032372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023032372 NPI number — NORTHWEST PRIMARY CARE GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST PRIMARY CARE GROUP 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:
6
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:
1023032372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22075
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKIE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97269-2075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-659-4777
Provider Business Mailing Address Fax Number:
503-652-5223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16144 SE HAPPY VALLEY TOWN CENTER DR STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAPPY VALLEY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97086-4257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-353-1272
Provider Business Practice Location Address Fax Number:
503-654-4815
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITBECK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
503-659-4777

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 022990 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: CE8055 . This is a "RAILROAD GROUP PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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