Basic Information
| Provider Information | |||||||||
| NPI: | 1447247416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCOY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | BUEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 847 NE 19TH AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632801 | ||||||||
| FaxNumber: | 5039632825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 NW 22ND AVE | ||||||||
| Address2: | STE 535 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972102900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032974999 | ||||||||
| FaxNumber: | 5037969884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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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 | 208800000X | MD13218 | OR | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | A008 | 01 | TRICARE | OTHER | C91743 | 01 | PROVIDENCE HEALTH | OTHER | 003395008 | 01 | BLUE CROSS OR ALL | OTHER | 930766376 | 01 | ADVENTIST MEDICAL | OTHER | 7858004 | 05 | WA | MEDICAID | 1040765 | 05 | WA | MEDICAID | 109371 | 05 | OR | MEDICAID | 930766376 | 01 | CAREOREGON | OTHER | M677A | 01 | HEALTH NET | OTHER | 180133 | 05 | OR | MEDICAID | 003395000 | 01 | BLUE CROSS OR ALL | OTHER | 128281 | 01 | WA | DEPT OF LABOR A | OTHER | 0079880 | 01 | WA | DEPT OF LABOR A | OTHER |