Provider Demographics
NPI:1922209832
Name:OREGON CITY MEDICAL NW INC.
Entity Type:Organization
Organization Name:OREGON CITY MEDICAL NW INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-656-9030
Mailing Address - Street 1:728 MOLALLA AVE STE A&B
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2799
Mailing Address - Country:US
Mailing Address - Phone:503-656-9030
Mailing Address - Fax:503-656-9026
Practice Address - Street 1:728 MOLALLA AVE STE A&B
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2799
Practice Address - Country:US
Practice Address - Phone:503-656-9030
Practice Address - Fax:503-656-9026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR838553000OtherBLUE CROSS GROUP ID
OR218463Medicaid