Provider Demographics
NPI:1558806406
Name:CHILDRENS CLINIC PC
Entity Type:Organization
Organization Name:CHILDRENS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH PLAN COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-535-6314
Mailing Address - Street 1:700 DEBORAH RD
Mailing Address - Street 2:STE 150
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-2198
Mailing Address - Country:US
Mailing Address - Phone:503-538-6791
Mailing Address - Fax:503-554-0549
Practice Address - Street 1:700 DEBORAH RD
Practice Address - Street 2:STE 150
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2198
Practice Address - Country:US
Practice Address - Phone:503-538-6791
Practice Address - Fax:503-554-0549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-02
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500730975Medicaid