Provider Demographics
NPI:1417922295
Name:GREWE, KENT MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:MICHAEL
Last Name:GREWE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N GRAHAM ST
Mailing Address - Street 2:STE 545
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227
Mailing Address - Country:US
Mailing Address - Phone:503-288-5151
Mailing Address - Fax:503-288-4942
Practice Address - Street 1:501 N GRAHAM ST
Practice Address - Street 2:STE 545
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227
Practice Address - Country:US
Practice Address - Phone:503-288-5151
Practice Address - Fax:503-288-4942
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13969207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR004197Medicaid
ORR00WCJVQAOtherPTAN
OR001782001OtherBLUE CROSS BLUE SHIELD
ORE33787Medicare UPIN