Basic Information
Provider Information | |||||||||
NPI: | 1568627594 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHILDERS | ||||||||
FirstName: | RYAN | ||||||||
MiddleName: | EDWIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 19250 SW 90TH AVE | ||||||||
Address2: |   | ||||||||
City: | TUALATIN | ||||||||
State: | OR | ||||||||
PostalCode: | 970627585 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036923750 | ||||||||
FaxNumber: | 5036912324 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2008 | ||||||||
LastUpdateDate: | 02/01/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D74059 | MD | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RG0100X | MD162161 | OR | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 500678079 | 05 | OR |   | MEDICAID | 055765000 | 05 | MD |   | MEDICAID |