Provider Demographics
NPI:1609068899
Name:STREAM, GLEN RITCHIE (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:RITCHIE
Last Name:STREAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:12518 NE AIRPORT WAY
Mailing Address - Street 2:CONCENTRA MEDICAL CENTERS
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230
Mailing Address - Country:US
Mailing Address - Phone:503-256-2992
Mailing Address - Fax:503-258-0717
Practice Address - Street 1:12518 NE AIRPORT WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1078
Practice Address - Country:US
Practice Address - Phone:503-256-2992
Practice Address - Fax:503-258-0717
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine