Provider Demographics
NPI:1275718157
Name:KELLY W RYDLUND, MD, LLC
Entity Type:Organization
Organization Name:KELLY W RYDLUND, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:W
Authorized Official - Last Name:RYDLUND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-656-0601
Mailing Address - Street 1:1508 DIVISION ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1582
Mailing Address - Country:US
Mailing Address - Phone:503-656-0601
Mailing Address - Fax:503-656-1389
Practice Address - Street 1:1508 DIVISION ST
Practice Address - Street 2:SUITE 115
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1582
Practice Address - Country:US
Practice Address - Phone:503-656-0601
Practice Address - Fax:503-656-1389
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KELLY W RYDLUND, MD, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25603207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR131493Medicare PIN
OR131492Medicare PIN
ORH07293Medicare UPIN