Provider Demographics
NPI:1790752533
Name:PORTLAND ADVENTIST MEDICAL CENTER
Entity Type:Organization
Organization Name:PORTLAND ADVENTIST MEDICAL CENTER
Other - Org Name:ADVENTIST MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:NEWMYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-257-2500
Mailing Address - Street 1:PO BOX 16800
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0800
Mailing Address - Country:US
Mailing Address - Phone:503-251-6141
Mailing Address - Fax:503-261-6643
Practice Address - Street 1:10123 SE MARKET ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2532
Practice Address - Country:US
Practice Address - Phone:503-251-6141
Practice Address - Fax:503-261-6643
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTLAND ADVENTIST MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-01
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0000889-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275183Medicaid
OR269070Medicaid