Basic Information
| Provider Information | |||||||||
| NPI: | 1972551976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THAYER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 SW OAK ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972041817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039883663 | ||||||||
| FaxNumber: | 5039884098 | ||||||||
| Practice Location | |||||||||
| Address1: | 426 SW STARK ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972042347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039885140 | ||||||||
| FaxNumber: | 5039885180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 08/28/2013 | ||||||||
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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 | 207R00000X | MD13684 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 105007 | 05 | OR | MEDICAID | 500628019 | 05 | OR | MEDICAID |