Provider Demographics
NPI:1528366986
Name:PEDIATRIC CARDIOLOGY CENTER OF OREGON PC
Entity Type:Organization
Organization Name:PEDIATRIC CARDIOLOGY CENTER OF OREGON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-280-3418
Mailing Address - Street 1:PO BOX 821350
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-0030
Mailing Address - Country:US
Mailing Address - Phone:360-667-3049
Mailing Address - Fax:360-666-0466
Practice Address - Street 1:971 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2503
Practice Address - Country:US
Practice Address - Phone:360-667-3049
Practice Address - Fax:360-666-0466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2080P0202X
WAMD000266642080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR057775000OtherREGENCE BLUE CROSS BLUE SHIELD OF OREGON
OR231812Medicaid
OR057775000OtherREGENCE BLUE CROSS BLUE SHIELD OF OREGON
OR0000WFBXLMedicare PIN