Provider Demographics
NPI:1477598159
Name:PORTLAND OBSTETRICS & GYNECOLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:PORTLAND OBSTETRICS & GYNECOLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SOFICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-229-7353
Mailing Address - Street 1:1130 NW 22ND AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-229-7353
Mailing Address - Fax:503-229-7255
Practice Address - Street 1:1130 NW 22ND AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-229-7353
Practice Address - Fax:503-229-7255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR174400000X
207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty