Provider Demographics
NPI:1235464868
Name:PORTLAND MEDICAL DIAGNOSTIC CENTER INC
Entity Type:Organization
Organization Name:PORTLAND MEDICAL DIAGNOSTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-408-7578
Mailing Address - Street 1:13232 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1573
Mailing Address - Country:US
Mailing Address - Phone:503-408-7578
Mailing Address - Fax:503-408-7615
Practice Address - Street 1:13232 SE STARK ST
Practice Address - Street 2:SUITE 4
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1573
Practice Address - Country:US
Practice Address - Phone:503-408-7578
Practice Address - Fax:503-408-7615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty