Basic Information
| Provider Information | |||||||||
| NPI: | 1154762078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWICK | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25180 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972980180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037976356 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Practice Location | |||||||||
| Address1: | 6190 RICE CREEK DR NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554325227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037976356 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2013 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 192192 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 500761493 | 05 | OR | MEDICAID | 65617 | 01 | MN | MINNESOTA MD PHYSICIAN AND SURGEON LICENSE | OTHER |