Provider Demographics
NPI:1003024423
Name:ROBERTS STREET CLINIC, P.C.
Entity Type:Organization
Organization Name:ROBERTS STREET CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-669-3066
Mailing Address - Street 1:400 NE ROBERTS AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7464
Mailing Address - Country:US
Mailing Address - Phone:503-669-3066
Mailing Address - Fax:503-665-6404
Practice Address - Street 1:400 NE ROBERTS AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7464
Practice Address - Country:US
Practice Address - Phone:503-669-3066
Practice Address - Fax:503-665-6404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO15150207Q00000X
ORDO21884207Q00000X
ORDO18839207Q00000X
ORMD17149207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR205823Medicaid
OR287658Medicaid
OR029582Medicaid
OR079546Medicaid
OR287698Medicaid
ORG23129Medicare UPIN
OR287658Medicaid
OR109162Medicare ID - Type Unspecified
OR08WFBBRAMedicare ID - Type Unspecified
OR029582Medicaid
ORH34118Medicare UPIN
OR0000WFBBRMedicare ID - Type Unspecified
OR011WFBBRAMedicare ID - Type Unspecified
ORE96441Medicare UPIN