Provider Demographics
NPI:1477636561
Name:PACIFIC MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:PACIFIC MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-598-2000
Mailing Address - Street 1:6 CENTERPOINTE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8660
Mailing Address - Country:US
Mailing Address - Phone:503-234-6381
Mailing Address - Fax:503-234-8151
Practice Address - Street 1:6 CENTERPOINTE DRIVE, STE 200
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035
Practice Address - Country:US
Practice Address - Phone:503-234-6381
Practice Address - Fax:503-234-8151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR230547Medicaid
ORCC6737OtherRR MEDICARE
OR230548Medicaid
OR230549Medicaid
OR230550Medicaid
OR230589Medicaid
OR230589Medicaid