Provider Demographics
NPI:1285667170
Name:IRISH, CHARLES EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWIN
Last Name:IRISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9155 SW BARNES RD
Mailing Address - Street 2:SUITE 830
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6625
Mailing Address - Country:US
Mailing Address - Phone:503-292-1103
Mailing Address - Fax:503-292-1433
Practice Address - Street 1:18650 NW CORNELL RD
Practice Address - Street 2:SUITE 212
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9207
Practice Address - Country:US
Practice Address - Phone:503-292-1103
Practice Address - Fax:503-292-1433
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2014-08-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD09659208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR234906Medicaid
ORE20958Medicare UPIN
OR234906Medicaid