Provider Demographics
NPI:1144383993
Name:TANASBOURNE FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:TANASBOURNE FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:GILPIN
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-614-8400
Mailing Address - Street 1:17200 NW CORRIDOR CT
Mailing Address - Street 2:STE 105
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-3295
Mailing Address - Country:US
Mailing Address - Phone:503-614-8400
Mailing Address - Fax:503-614-8411
Practice Address - Street 1:17200 NW CORRIDOR CT
Practice Address - Street 2:STE 105
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-3295
Practice Address - Country:US
Practice Address - Phone:503-614-8400
Practice Address - Fax:503-614-8411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR154344Medicaid
OR154344Medicaid
ORC91338Medicare UPIN