Provider Demographics
NPI:1487817508
Name:PACIFIC HEART ASSOCIATES PC
Entity Type:Organization
Organization Name:PACIFIC HEART ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUSCHOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-790-0230
Mailing Address - Street 1:1040 NW 22ND AVE
Mailing Address - Street 2:SUITE 660
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3057
Mailing Address - Country:US
Mailing Address - Phone:503-790-1234
Mailing Address - Fax:
Practice Address - Street 1:174 FIRST AVE N
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624
Practice Address - Country:US
Practice Address - Phone:888-414-7558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287001Medicaid
WA7111966Medicaid
WAG8857209Medicare PIN
ORR0000WCHVVMedicare PIN