Provider Demographics
NPI:1922285238
Name:EAST PORTLAND MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:EAST PORTLAND MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERTRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-230-4811
Mailing Address - Street 1:7524 SE MILWAUKIE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6113
Mailing Address - Country:US
Mailing Address - Phone:503-230-4811
Mailing Address - Fax:503-249-1872
Practice Address - Street 1:7524 SE MILWAUKIE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6113
Practice Address - Country:US
Practice Address - Phone:503-230-4811
Practice Address - Fax:503-249-1872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16449207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR110398OtherMEDICARE GRP PROVIDER #