1881701381 NPI number — OREGON CARDIOLOGY CLINIC PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881701381 NPI number — OREGON CARDIOLOGY CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OREGON CARDIOLOGY CLINIC 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:
1881701381
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:
501 N GRAHAM ST
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97227-2006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-288-8385
Provider Business Mailing Address Fax Number:
503-288-6789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 N GRAHAM ST
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97227-2006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-288-8385
Provider Business Practice Location Address Fax Number:
503-288-6789
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDBERG
Authorized Official First Name:
LEONARD
Authorized Official Middle Name:
MARVIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-288-8385

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  MD05410 , 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: 074286 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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