Basic Information
| Provider Information | |||||||||
| NPI: | 1659363000 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KREMKAU | ||||||||
| FirstName: | EDNA | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 SE SANDY BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632846 | ||||||||
| FaxNumber: | 5039639505 | ||||||||
| Practice Location | |||||||||
| Address1: | 507 NE 47TH AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972132236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032152300 | ||||||||
| FaxNumber: | 5032152283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD06932 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 8222507 | 05 | OR | MEDICAID | 261297 | 05 | OR | MEDICAID |