Basic Information
| Provider Information | |||||||||
| NPI: | 1033232996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYES | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | BENTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34353 CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970539609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033970598 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1027 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032398400 | ||||||||
| FaxNumber: | 5032398406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | OR 12570 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 223719 | 05 | OR | MEDICAID |