Basic Information
| Provider Information | |||||||||
| NPI: | 1285608059 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS CARDIAC CENTER PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9155 SW BARNES RD | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032964027 | ||||||||
| FaxNumber: | 5032162488 | ||||||||
| Practice Location | |||||||||
| Address1: | 9155 SW BARNES RD | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032964027 | ||||||||
| FaxNumber: | 5032162488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 10/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | STARR | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 5032964027 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | OR | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 7063332 | 01 | WA | WELFARE | OTHER | 061390 | 05 | OR | MEDICAID |