Provider Demographics
NPI:1174857833
Name:EYE HEALTH NORTHWEST P.C.
Entity Type:Organization
Organization Name:EYE HEALTH NORTHWEST P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:K
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-255-2291
Mailing Address - Street 1:11086 SE OAK ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6692
Mailing Address - Country:US
Mailing Address - Phone:503-557-2020
Mailing Address - Fax:503-344-5110
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 245
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-255-2291
Practice Address - Fax:503-252-1797
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYE HEALTH NORTHWEST P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-29
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR085006Medicaid
ORR0000WFBZKFMedicare PIN
OR085006Medicaid