Provider Demographics
NPI:1225184674
Name:GRESHAM TROUTDALE FAMILY MEDICAL CENTER PC
Entity Type:Organization
Organization Name:GRESHAM TROUTDALE FAMILY MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KNOPF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-491-2422
Mailing Address - Street 1:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-0730
Mailing Address - Country:US
Mailing Address - Phone:503-491-2422
Mailing Address - Fax:503-491-2434
Practice Address - Street 1:1700 SW 257TH AVE
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060-1900
Practice Address - Country:US
Practice Address - Phone:503-491-2422
Practice Address - Fax:503-491-2434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR228757Medicaid
OR=========OtherUNITED HEALTHCARE
OR=========OtherPROVIDENCE HEALTH PLANS
OR=========OtherHEALTHNET
OR=========OtherAETNA
OR=========OtherODS
OR228757Medicaid
OR0000WFBZJMedicare PIN