Provider Demographics
NPI:1326079062
Name:DONALD W FROOM MDLLC
Entity Type:Organization
Organization Name:DONALD W FROOM MDLLC
Other - Org Name:DONALD W FROOM MDPC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:LLC
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WOODROW
Authorized Official - Last Name:FROOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-292-7721
Mailing Address - Street 1:9155 SW BARNES RD
Mailing Address - Street 2:STE 534
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6625
Mailing Address - Country:US
Mailing Address - Phone:503-292-7721
Mailing Address - Fax:503-292-6455
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:STE 534
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-292-7721
Practice Address - Fax:503-292-6455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMDO6973174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR061861Medicaid
OR061861Medicaid
C94326Medicare UPIN