Provider Demographics
NPI:1558548529
Name:JOEL AMUNDSON MD PC
Entity Type:Organization
Organization Name:JOEL AMUNDSON MD PC
Other - Org Name:DR. JOEL'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:AMUNDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-342-2180
Mailing Address - Street 1:5231 NE MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3235
Mailing Address - Country:US
Mailing Address - Phone:503-342-2180
Mailing Address - Fax:503-208-8023
Practice Address - Street 1:5231 NE MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3235
Practice Address - Country:US
Practice Address - Phone:503-342-2180
Practice Address - Fax:503-208-8023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR003334053OtherREGENCE BLUESHIELD
OR278409Medicaid