Provider Demographics
NPI:1922304302
Name:EASTSIDE ALLERGY ASTHMA & GENERAL INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:EASTSIDE ALLERGY ASTHMA & GENERAL INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:UNDERWOOD
Authorized Official - Last Name:SARGENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:503-666-5025
Mailing Address - Street 1:2850 SE POWELL BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-1494
Mailing Address - Country:US
Mailing Address - Phone:503-666-5025
Mailing Address - Fax:503-666-5795
Practice Address - Street 1:2850 SE POWELL BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1494
Practice Address - Country:US
Practice Address - Phone:503-666-5025
Practice Address - Fax:503-666-5795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTSIDE ALLERGY, ASTHMA & GENERAL INTERNAL MEDICINE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21072207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151110Medicaid
OR1011646Medicare PIN
OR151110Medicaid