Provider Demographics
NPI:1639356991
Name:OHSU MEDICAL GROUP
Entity Type:Organization
Organization Name:OHSU MEDICAL GROUP
Other - Org Name:OHSU MEDICAL GROUP IN LONGVIEW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-494-9616
Mailing Address - Street 1:2241 LLOYD CENTER
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1315
Mailing Address - Country:US
Mailing Address - Phone:503-494-8417
Mailing Address - Fax:503-494-4455
Practice Address - Street 1:1060 HUDSON ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3103
Practice Address - Country:US
Practice Address - Phone:360-414-1388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHSU MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8855611Medicare PIN