Basic Information
| Provider Information | |||||||||
| NPI: | 1023583994 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORTLAND ADVENTIST MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | ADVENTIST HEALTH PORTLAND - CLACKAMAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 888918 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900888918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032616085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10151 SE SUNNYSIDE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036590880 | ||||||||
| FaxNumber: | 5035137425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2018 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WELCH | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | EUGENE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5032614406 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PORTLAND ADVENTIST MEDICAL CENTER | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.