Provider Demographics
NPI:1922559764
Name:KAISER PERMANANTE
Entity Type:Organization
Organization Name:KAISER PERMANANTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MILIEU COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHYBUT
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:503-652-2880
Mailing Address - Street 1:6935 N RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4933
Mailing Address - Country:US
Mailing Address - Phone:503-728-8581
Mailing Address - Fax:
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-652-2880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit