Provider Demographics
NPI:1477518637
Name:GRISHKEVICH, MAX V (MD)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:V
Last Name:GRISHKEVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MAKSIM
Other - Middle Name:V
Other - Last Name:GRISHKEVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 SE 182ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5692
Practice Address - Country:US
Practice Address - Phone:503-661-3439
Practice Address - Fax:503-699-1360
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23093207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287143Medicaid
OR110327Medicare ID - Type Unspecified
OR287143Medicaid