Provider Demographics
NPI:1639175813
Name:CLEARY MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:CLEARY MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:SHANNAHAN
Authorized Official - Last Name:CLEARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-520-0777
Mailing Address - Street 1:PO BOX 23200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97281-3200
Mailing Address - Country:US
Mailing Address - Phone:503-520-0777
Mailing Address - Fax:503-520-0559
Practice Address - Street 1:11786 SW BARNES RD
Practice Address - Street 2:STE 270
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5929
Practice Address - Country:US
Practice Address - Phone:503-520-0777
Practice Address - Fax:503-520-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR109009Medicaid
OR109009Medicaid
ORC92052Medicare UPIN