Basic Information
| Provider Information | |||||||||
| NPI: | 1912123639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRASMEDER | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | MARTIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4555 N WILLIAMS AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972172955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9713734165 | ||||||||
| FaxNumber: | 5036308551 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 NE 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | ESTACADA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970239312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036308550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD14828 | OR | N | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | MD14828 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 214155 | 05 | OR | MEDICAID | 096511 | 05 | OR | MEDICAID | 22959 | 05 | OR | MEDICAID |