Basic Information
| Provider Information | |||||||||
| NPI: | 1427153238 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | KAI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 CENTERPOINTE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970358660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037972268 | ||||||||
| FaxNumber: | 5032348227 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 MOLALLA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970453753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036565273 | ||||||||
| FaxNumber: | 5036504828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 05/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD26746 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 240159 | 05 | OR | MEDICAID |