Provider Demographics
NPI:1023226271
Name:RIVER MEDICAL CLINIC PC
Entity type:Organization
Organization Name:RIVER MEDICAL CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-260-8225
Mailing Address - Street 1:PO BOX 33348
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-3348
Mailing Address - Country:US
Mailing Address - Phone:360-260-8225
Mailing Address - Fax:360-397-0189
Practice Address - Street 1:13021 SE RIVER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97222-8062
Practice Address - Country:US
Practice Address - Phone:360-260-8225
Practice Address - Fax:360-397-0189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15086207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR196295Medicaid
OR196295Medicaid
OR106332Medicare ID - Type UnspecifiedMEDICARE GROUP