Provider Demographics
NPI:1104834969
Name:LEGACY MOUNT HOOD MEDICAL CENTER
Entity Type:Organization
Organization Name:LEGACY MOUNT HOOD MEDICAL CENTER
Other - Org Name:LEGACY MT. HOOD RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:VUKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-415-5370
Mailing Address - Street 1:PO BOX 10768
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97296-0768
Mailing Address - Country:US
Mailing Address - Phone:503-674-1233
Mailing Address - Fax:503-674-1647
Practice Address - Street 1:24800 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3378
Practice Address - Country:US
Practice Address - Phone:503-674-1233
Practice Address - Fax:503-674-1647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14 13372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240079Medicaid
OR134624Medicare ID - Type Unspecified