Provider Demographics
NPI:1083686554
Name:SELLWOOD MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:SELLWOOD MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNOZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-595-9300
Mailing Address - Street 1:8332 SE 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7102
Mailing Address - Country:US
Mailing Address - Phone:503-595-9300
Mailing Address - Fax:503-233-1892
Practice Address - Street 1:8332 SE 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7102
Practice Address - Country:US
Practice Address - Phone:503-595-9300
Practice Address - Fax:503-233-1892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11101207Q00000X
ORMD06704207RC0000X
ORP83603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR181036Medicare UPIN
ORE03511Medicare UPIN
ORR115292Medicare UPIN
ORF91660Medicare UPIN
ORR179182Medicare UPIN
ORP83603Medicare UPIN
ORF91660Medicare UPIN