Basic Information
| Provider Information | |||||||||
| NPI: | 1285683656 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC & FRACTURE CLINIC PC | ||||||||
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| OtherOrganizationName: | ORTHOPEDIC AND FRACTURE SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11782 SW BARNES RD | ||||||||
| Address2: | SUITE 300, BLDG C | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032145200 | ||||||||
| FaxNumber: | 5039066613 | ||||||||
| Practice Location | |||||||||
| Address1: | 11782 SW BARNES RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032145200 | ||||||||
| FaxNumber: | 5039066613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEBSTER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALST | ||||||||
| AuthorizedOfficialTelephone: | 5039064302 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0004X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 273850 | 05 | OR | MEDICAID |