Provider Demographics
NPI:1073030730
Name:KAISER FOUNDATION HEALTH PLAN NORTHWEST
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN NORTHWEST
Other - Org Name:KAISER PERMANENTE 3 TO PHD WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:BARTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-813-2440
Mailing Address - Street 1:500 NE MULTNOMAH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2023
Mailing Address - Country:US
Mailing Address - Phone:800-813-2000
Mailing Address - Fax:503-286-6879
Practice Address - Street 1:2930 NE DEKUM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-6613
Practice Address - Country:US
Practice Address - Phone:800-813-2000
Practice Address - Fax:503-286-6879
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KAISER FOUNDATION HEALTH PLAN NORTHWEST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-24
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR147090Medicaid
WA7857501Medicaid