Basic Information
| Provider Information | |||||||||
| NPI: | 1194147074 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTLAND ADVENTIST MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | ADVENTIST HEALTH PORTLAND - INTERNAL MEDICINE ASSOCIATES | ||||||||
| 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: | 10201 SE MAIN ST STE 12 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032557550 | ||||||||
| FaxNumber: | 5032550884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2014 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | WELCH | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5032614405 | ||||||||
| 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 | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.