Basic Information
| Provider Information | |||||||||
| NPI: | 1548467129 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST PEDIATRIC GASTROENTEROLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 N GRAHAM ST | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032815139 | ||||||||
| FaxNumber: | 5032493782 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 N GRAHAM ST | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032815139 | ||||||||
| FaxNumber: | 5032493782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 07/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | SCHULZ | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5032815139 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | OREGON | 05 | OR | MEDICAID | WASHINGTON | 05 | WA | MEDICAID |