Provider Demographics
NPI:1053311670
Name:KERENSKY, MARCIA M (MD)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:M
Last Name:KERENSKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:K
Other - Last Name:COODLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2400 SW VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1940
Mailing Address - Country:US
Mailing Address - Phone:503-452-0915
Mailing Address - Fax:503-768-9232
Practice Address - Street 1:2400 SW VERMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-1940
Practice Address - Country:US
Practice Address - Phone:503-452-0915
Practice Address - Fax:503-768-9232
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR060413Medicaid
E01902Medicare UPIN
OR060413Medicaid