Provider Demographics
NPI:1093929226
Name:WESTSIDE PEDIATRIC CLINIC PC
Entity Type:Organization
Organization Name:WESTSIDE PEDIATRIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-297-1025
Mailing Address - Street 1:9555 SW BARNES RD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225
Mailing Address - Country:US
Mailing Address - Phone:503-297-1025
Mailing Address - Fax:503-297-1043
Practice Address - Street 1:9555 SW BARNES RD
Practice Address - Street 2:SUITE 270
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-297-1025
Practice Address - Fax:503-297-1043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150220Medicaid