Basic Information
| Provider Information | |||||||||
| NPI: | 1821073701 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENDLETON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LOWRIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 WEBBER ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412984160 | ||||||||
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| Practice Location | |||||||||
| Address1: | 849 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | HOOD RIVER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970311956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413088370 | ||||||||
| FaxNumber: | 5413080754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 12/22/2017 | ||||||||
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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 | 207Q00000X | 22825 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD14783 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8105546 | 05 | WA | MEDICAID | 174995 | 05 | OR | MEDICAID | 136170 | 01 | WA | DEPT OF LABOR AND INDUSTR | OTHER | 080028716 | 01 | RAILROAD MEDICARE | OTHER | 1256028 | 01 | UNITED HEALTHCARE | OTHER | 11002 | 01 | BLUE CROSS BLUE SHIELD | OTHER | K066920 | 01 | KY | MEDICARE -NORTON IMMEDIATE CARE CENTER | OTHER | K5099 02 | 01 | PACIFIC SOURCE | OTHER |