Basic Information
| Provider Information | |||||||||
| NPI: | 1508830621 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCANINCH | ||||||||
| FirstName: | MALCOLM | ||||||||
| MiddleName: | LEWIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9450 SW BARNES RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032929560 | ||||||||
| FaxNumber: | 5032929510 | ||||||||
| Practice Location | |||||||||
| Address1: | 9450 SW BARNES RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032929560 | ||||||||
| FaxNumber: | 5032929510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 05/25/2012 | ||||||||
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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 | 13341 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 143966 | 05 | OR | MEDICAID |