Provider Demographics
NPI:1922365956
Name:DERMATOLOGY NORTHWEST LLC
Entity Type:Organization
Organization Name:DERMATOLOGY NORTHWEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:LITKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-463-6799
Mailing Address - Street 1:5900 INLAND SHORES WAY
Mailing Address - Street 2:STE 202
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303
Mailing Address - Country:US
Mailing Address - Phone:503-463-6799
Mailing Address - Fax:503-463-6771
Practice Address - Street 1:5900 INLAND SHORES WAY N
Practice Address - Street 2:STE 202
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-3883
Practice Address - Country:US
Practice Address - Phone:503-463-6799
Practice Address - Fax:503-463-6771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10836174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty