Basic Information
| Provider Information | |||||||||
| NPI: | 1194987206 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATIVE PEDIATRICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11790 SW BARNES RD | ||||||||
| Address2: | BLG. A, SUITE 140 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036432100 | ||||||||
| FaxNumber: | 5036437300 | ||||||||
| Practice Location | |||||||||
| Address1: | 11790 SW BARNES RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036432100 | ||||||||
| FaxNumber: | 5036437300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 08/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | NORMAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5036432100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD15689 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.