Provider Demographics
NPI:1053832162
Name:TUALATIN INTERNAL MEDICINE
Entity Type:Organization
Organization Name:TUALATIN INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:N
Authorized Official - Last Name:GLASER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-272-8825
Mailing Address - Street 1:6485 SW BORLAND RD STE B
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9762
Mailing Address - Country:US
Mailing Address - Phone:503-272-8825
Mailing Address - Fax:503-427-9321
Practice Address - Street 1:6485 SW BORLAND RD STE B
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9762
Practice Address - Country:US
Practice Address - Phone:503-272-8825
Practice Address - Fax:503-427-9321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD164199207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500673474Medicaid