1679742217 NPI number — WILLAMETTE FALLS FAMILY MEDICINE

Table of content: (NPI 1679742217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679742217 NPI number — WILLAMETTE FALLS FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLAMETTE FALLS FAMILY MEDICINE
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:
1679742217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 JOHN ADAMS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OREGON CITY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97045-1955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-657-3034
Provider Business Mailing Address Fax Number:
503-657-1785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 JOHN ADAMS ST
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:
97045-1955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-657-3034
Provider Business Practice Location Address Fax Number:
503-657-1785
Provider Enumeration Date:
02/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PHAM
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
503-657-3034

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  DO23388 , 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)





Copyright © 2007-2025 www.npivalidator.com