Provider Demographics
NPI:1780638411
Name:JAMES H PETERSEN MD PC
Entity Type:Organization
Organization Name:JAMES H PETERSEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:503-297-7223
Mailing Address - Street 1:5319 SW WESTGATE DR
Mailing Address - Street 2:#241
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2432
Mailing Address - Country:US
Mailing Address - Phone:503-297-7223
Mailing Address - Fax:503-297-7603
Practice Address - Street 1:900 SUNSET DRIVE
Practice Address - Street 2:GRANDE RHOODE HOSPITAL
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850
Practice Address - Country:US
Practice Address - Phone:541-963-1401
Practice Address - Fax:541-963-1502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08688207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR062013Medicaid
D42505Medicare UPIN
OR062013Medicaid