Basic Information
| Provider Information | |||||||||
| NPI: | 1073879268 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OREGON HEALTH AND SCIENCE UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OHSU CHILD DEVELOPMENT & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 574 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972070574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034942709 | ||||||||
| FaxNumber: | 5034946868 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 SW GAINES ST | ||||||||
| Address2: | MAILCODE: CDRC -- ATTN: JEFF REHA | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972392901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034942709 | ||||||||
| FaxNumber: | 5034946868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2012 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | UNIVERSITY PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5034948252 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D., M.B.A. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.