1356327803 NPI number — CASCADE OCCUPATIONAL MEDICINE PHYSICIANS INC

Table of content: (NPI 1356327803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356327803 NPI number — CASCADE OCCUPATIONAL MEDICINE PHYSICIANS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CASCADE OCCUPATIONAL MEDICINE PHYSICIANS INC
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:
1356327803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1548
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97035-0748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-594-1118
Provider Business Mailing Address Fax Number:
503-635-8354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6464 SW BORLAND RD
Provider Second Line Business Practice Location Address:
SUITE B5
Provider Business Practice Location Address City Name:
TUALATIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97062-8876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-885-8793
Provider Business Practice Location Address Fax Number:
503-885-0787
Provider Enumeration Date:
12/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BRADDOCK
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CEO MEDICAL DIRECTOR
Authorized Official Telephone Number:
503-635-1960

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 0141626 . This is a "DEPT OF LABOR AND INDUSTR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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