Basic Information
| Provider Information | |||||||||
| NPI: | 1871050153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC & FRACTURE CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11782 SW BARNES RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039064302 | ||||||||
| FaxNumber: | 5038403004 | ||||||||
| Practice Location | |||||||||
| Address1: | 11782 SW BARNES RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032145200 | ||||||||
| FaxNumber: | 5039066613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2019 | ||||||||
| LastUpdateDate: | 02/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | J BRAD | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5032145200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORTHOPEDIC & FRACTURE CLINIC, PC | ||||||||
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| AuthorizedOfficialNameSuffix: | V | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 146456 | 05 | OR | MEDICAID |