Provider Demographics
NPI:1336328608
Name:MARK STEVEN METZGER MD PC
Entity Type:Organization
Organization Name:MARK STEVEN METZGER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINIASTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-256-5866
Mailing Address - Street 1:10000 SE MAIN ST
Mailing Address - Street 2:SUITE 327
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2448
Mailing Address - Country:US
Mailing Address - Phone:503-256-5866
Mailing Address - Fax:503-254-0656
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:SUITE 327
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-256-5866
Practice Address - Fax:503-254-0656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23691174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR6249600001Medicare NSC
ORH57948Medicare UPIN
ORR139520Medicare PIN