Provider Demographics
NPI:1790969624
Name:WOODBURN PEDIATRIC CLINIC LLP
Entity Type:Organization
Organization Name:WOODBURN PEDIATRIC CLINIC LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:BARTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-981-1236
Mailing Address - Street 1:2050 PROGRESS WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-9764
Mailing Address - Country:US
Mailing Address - Phone:503-981-5348
Mailing Address - Fax:503-981-0423
Practice Address - Street 1:2050 PROGRESS WAY
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9764
Practice Address - Country:US
Practice Address - Phone:503-981-5348
Practice Address - Fax:503-981-0423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08572208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182287Medicaid