Provider Demographics
NPI:1821073701
Name:PENDLETON, MICHAEL LOWRIE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LOWRIE
Last Name:PENDLETON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 WEBBER ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3749
Mailing Address - Country:US
Mailing Address - Phone:541-298-4160
Mailing Address - Fax:
Practice Address - Street 1:849 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1956
Practice Address - Country:US
Practice Address - Phone:541-308-8370
Practice Address - Fax:541-308-0754
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22825207Q00000X
ORMD14783207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8105546Medicaid
OR174995Medicaid
WA136170OtherDEPT OF LABOR AND INDUSTR
080028716OtherRAILROAD MEDICARE
1256028OtherUNITED HEALTHCARE
11002OtherBLUE CROSS BLUE SHIELD
KYK066920OtherMEDICARE -NORTON IMMEDIATE CARE CENTER
K5099 02OtherPACIFIC SOURCE
OR174995Medicaid
000WCJPVCMedicare ID - Type Unspecified