Provider Demographics
NPI:1790964062
Name:CHARLES TODD WOOLLEY MD PC
Entity Type:Organization
Organization Name:CHARLES TODD WOOLLEY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-253-3268
Mailing Address - Street 1:10101 SE MAIN ST
Mailing Address - Street 2:SUITE 3008
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2455
Mailing Address - Country:US
Mailing Address - Phone:503-253-3268
Mailing Address - Fax:503-253-1530
Practice Address - Street 1:10101 SE MAIN ST
Practice Address - Street 2:SUITE 3008
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2455
Practice Address - Country:US
Practice Address - Phone:503-253-3268
Practice Address - Fax:503-253-1530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23565174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH27437Medicare UPIN