Provider Demographics
NPI:1346218369
Name:OAK GROVE FAMILY MEDICAL CLINIC P C
Entity Type:Organization
Organization Name:OAK GROVE FAMILY MEDICAL CLINIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MIKKELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-653-1860
Mailing Address - Street 1:2250 SE OAK GROVE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-2670
Mailing Address - Country:US
Mailing Address - Phone:503-654-6567
Mailing Address - Fax:503-653-2582
Practice Address - Street 1:2250 SE OAK GROVE BLVD #B
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-2670
Practice Address - Country:US
Practice Address - Phone:503-654-6567
Practice Address - Fax:503-653-2582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORA001OtherCHAMPUS
ORCF9670OtherRAILROAD MEDICARE
OR067039000OtherBLUE CROSS
ORA001OtherCHAMPUS
OR287591Medicaid