Provider Demographics
NPI:1477524577
Name:PACIFIC DIGESTIVE ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:PACIFIC DIGESTIVE ASSOCIATES, P.C.
Other - Org Name:PACIFIC DIGESTIVE ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-496-0354
Mailing Address - Street 1:15775 SE 82ND DR
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8551
Mailing Address - Country:US
Mailing Address - Phone:503-722-9155
Mailing Address - Fax:503-722-0420
Practice Address - Street 1:15775 SE 82ND DR
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8551
Practice Address - Country:US
Practice Address - Phone:503-722-9155
Practice Address - Fax:503-722-0420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-28
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR071559261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269582Medicaid
OR269582Medicaid