Basic Information
| Provider Information | |||||||||
| NPI: | 1356327803 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CASCADE OCCUPATIONAL MEDICINE PHYSICIANS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1548 | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970350748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035941118 | ||||||||
| FaxNumber: | 5036358354 | ||||||||
| Practice Location | |||||||||
| Address1: | 6464 SW BORLAND RD | ||||||||
| Address2: | SUITE B5 | ||||||||
| City: | TUALATIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970628876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038858793 | ||||||||
| FaxNumber: | 5038850787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BRADDOCK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5036351960 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QX0100X | X | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0141626 | 01 | WA | DEPT OF LABOR AND INDUSTR | OTHER |