Provider Demographics
NPI:1396177937
Name:BRIDGETOWN MEDICAL GROUP P.C.
Entity Type:Organization
Organization Name:BRIDGETOWN MEDICAL GROUP P.C.
Other - Org Name:BRIDGETOWN WOMEN'C CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-416-6510
Mailing Address - Street 1:10000 SE MAIN ST
Mailing Address - Street 2:SUITE 248
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2448
Mailing Address - Country:US
Mailing Address - Phone:503-416-6510
Mailing Address - Fax:503-416-6529
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:SUITE 212
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216
Practice Address - Country:US
Practice Address - Phone:503-257-6919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR076037162N5176B00000X
ORMD17656207V00000X
ORMD12584207V00000X
ORMD10669207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR070490Medicaid
OR070490Medicaid