Provider Demographics
NPI:1992855829
Name:PATRICK RADECKI, M.D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PATRICK RADECKI, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:RADECKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-222-3638
Mailing Address - Street 1:2222 NW LOVEJOY ST STE 607
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5104
Mailing Address - Country:US
Mailing Address - Phone:503-222-3638
Mailing Address - Fax:503-222-3638
Practice Address - Street 1:2222 NW LOVEJOY ST STE 607
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5104
Practice Address - Country:US
Practice Address - Phone:503-222-3638
Practice Address - Fax:503-222-3638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13579174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR291880Medicaid
OR291880Medicaid