Provider Demographics
NPI:1891741864
Name:KNOTT STREET DERMATOLOGY PC
Entity Type:Organization
Organization Name:KNOTT STREET DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:LEIF
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-253-3910
Mailing Address - Street 1:301 NE KNOTT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3014
Mailing Address - Country:US
Mailing Address - Phone:503-253-2675
Mailing Address - Fax:503-253-4297
Practice Address - Street 1:301 NE KNOTT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3014
Practice Address - Country:US
Practice Address - Phone:503-253-2675
Practice Address - Fax:503-253-4297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26393174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H61417Medicare UPIN
ORR134757Medicare PIN