Provider Demographics
NPI:1619205440
Name:PORTLAND JOINT RECONSTRUCTION CLINIC, P.C.
Entity Type:Organization
Organization Name:PORTLAND JOINT RECONSTRUCTION CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:HIKES
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:503-239-7099
Mailing Address - Street 1:5050 NE HOYT STREET
Mailing Address - Street 2:SUITE 668
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2990
Mailing Address - Country:US
Mailing Address - Phone:503-239-7099
Mailing Address - Fax:503-239-9459
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 668
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-239-7099
Practice Address - Fax:503-239-9459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11185207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE04186Medicare UPIN