Provider Demographics
NPI:1942292891
Name:DALLAS FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:DALLAS FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:W
Authorized Official - Last Name:EDWARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-623-2345
Mailing Address - Street 1:641 SE MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-2634
Mailing Address - Country:US
Mailing Address - Phone:503-623-2345
Mailing Address - Fax:503-623-6071
Practice Address - Street 1:641 SE MILLER AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-2634
Practice Address - Country:US
Practice Address - Phone:503-623-2345
Practice Address - Fax:503-623-6071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2012-10-22
Deactivation Date:2005-08-30
Deactivation Code:
Reactivation Date:2008-01-14
Provider Licenses
StateLicense IDTaxonomies
ORMD13699174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty