Provider Demographics
NPI:1760869739
Name:OREGON CITY MEDICAL NW, INC
Entity Type:Organization
Organization Name:OREGON CITY MEDICAL NW, INC
Other - Org Name:TUALATIN FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FNP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:503-656-9030
Mailing Address - Street 1:6464 SW BORLAND ROAD #D-4
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6464 SW BORLAND ROAD #D-4
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-487-3001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1500005833261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218463Medicaid
ORR142037OtherPTAN