Provider Demographics
NPI:1780865642
Name:NORTHWEST RENAL CLINIC, INC.
Entity Type:Organization
Organization Name:NORTHWEST RENAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-229-7976
Mailing Address - Street 1:1130 NW 22ND AVENUE
Mailing Address - Street 2:SUITE 640
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-229-7976
Mailing Address - Fax:503-274-4867
Practice Address - Street 1:9155 SW BARNES RD STE 402
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6631
Practice Address - Country:US
Practice Address - Phone:503-292-7704
Practice Address - Fax:503-292-7046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR119297Medicaid
OR119297Medicaid
R0000WCGSJMedicare PIN