Basic Information
| Provider Information | |||||||||
| NPI: | 1568401420 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY PHYSICIANS OF PORTLAND, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 21ST AVE S | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372124314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152690652 | ||||||||
| FaxNumber: | 6152690135 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 REDBUD DR | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371481673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153257301 | ||||||||
| FaxNumber: | 6152690135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 12/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | DUKE | ||||||||
| AuthorizedOfficialFirstName: | HAROLD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6152690652 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3734968 | 05 | TN | MEDICAID |