Provider Demographics
NPI:1003008665
Name:KISHORE G. PATHIAL, M.D., P.C.
Entity type:Organization
Organization Name:KISHORE G. PATHIAL, M.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KISHORE
Authorized Official - Middle Name:GOPINATHAN
Authorized Official - Last Name:PATHIAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-472-5163
Mailing Address - Street 1:2397 NE CUMULUS AVE.
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6255
Mailing Address - Country:US
Mailing Address - Phone:503-472-5163
Mailing Address - Fax:503-472-3320
Practice Address - Street 1:2397 NE CUMULUS AVE.
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6255
Practice Address - Country:US
Practice Address - Phone:503-472-5163
Practice Address - Fax:503-472-5163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR094006411N3 ANP-PP163W00000X
OR695279-1207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR117632Medicare UPIN
ORR117634Medicare UPIN
ORE94892Medicare UPIN
PAR119483Medicare UPIN