Provider Demographics
NPI:1891742318
Name:GRESHAM PODIATRY CENTER, LLC
Entity Type:Organization
Organization Name:GRESHAM PODIATRY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MCCAMMON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-667-6600
Mailing Address - Street 1:831 NW COUNCIL DR
Mailing Address - Street 2:SUITE #203
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3721
Mailing Address - Country:US
Mailing Address - Phone:503-667-6600
Mailing Address - Fax:503-667-6608
Practice Address - Street 1:831 NW COUNCIL DR
Practice Address - Street 2:SUITE #203
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3721
Practice Address - Country:US
Practice Address - Phone:503-667-6600
Practice Address - Fax:503-667-6608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR307213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1891742318OtherGROUP NPI
ORR107949Medicare ID - Type UnspecifiedGROUP MEDICARE ID NUMBER
OR3897300001Medicare NSC
OR1891742318OtherGROUP NPI