Provider Demographics
NPI:1558719450
Name:ASCENSION MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:ASCENSION MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER-MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:971-804-1906
Mailing Address - Street 1:700 N HAYDEN ISLAND DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-8130
Mailing Address - Country:US
Mailing Address - Phone:971-533-5840
Mailing Address - Fax:971-270-2806
Practice Address - Street 1:700 N HAYDEN ISLAND DR STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-8130
Practice Address - Country:US
Practice Address - Phone:971-533-5840
Practice Address - Fax:971-270-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty