Provider Demographics
NPI:1528220936
Name:WILLAMETTE FALLS PEDIATRIC GROUP, PC
Entity Type:Organization
Organization Name:WILLAMETTE FALLS PEDIATRIC GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GRUCELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-905-3400
Mailing Address - Street 1:1510 DIVISION ST
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1581
Mailing Address - Country:US
Mailing Address - Phone:503-905-3400
Mailing Address - Fax:503-905-3399
Practice Address - Street 1:200 SOUTH HAZEL DELL WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013
Practice Address - Country:US
Practice Address - Phone:503-266-8500
Practice Address - Fax:503-266-8585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1292945-0208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028484Medicaid