Provider Demographics
NPI:1861664781
Name:WIMAHL FAMILY CLINIC, PC
Entity Type:Organization
Organization Name:WIMAHL FAMILY CLINIC, PC
Other - Org Name:WIMAHL FAMILY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-338-2993
Mailing Address - Street 1:2120 EXCHANGE ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3365
Mailing Address - Country:US
Mailing Address - Phone:503-338-2993
Mailing Address - Fax:503-338-2996
Practice Address - Street 1:2120 EXCHANGE ST
Practice Address - Street 2:SUITE 209
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3365
Practice Address - Country:US
Practice Address - Phone:503-338-2993
Practice Address - Fax:503-338-2996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24702207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8377632Medicaid
OR275225Medicaid
OR275225Medicaid
WA8377632Medicaid