Basic Information
| Provider Information | |||||||||
| NPI: | 1417217894 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROSE CITY MEDICAL LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ROSE CITY URGENT CARE AND FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 NE 102ND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972204167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038949005 | ||||||||
| FaxNumber: | 5037194178 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 NE 102ND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972204167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038949005 | ||||||||
| FaxNumber: | 5037194178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2012 | ||||||||
| LastUpdateDate: | 02/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5038949005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 85696897 | OR | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261Q00000X | 85696897 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 500646730 | 05 | OR | MEDICAID | R167408 | 01 | OR | MEDICARE PTAN | OTHER |