Provider Demographics
NPI:1134204340
Name:GRESHAM INTERNAL MEDICINE CLINIC
Entity type:Organization
Organization Name:GRESHAM INTERNAL MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CUSTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-667-1015
Mailing Address - Street 1:PO BOX 23200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97281-3200
Mailing Address - Country:US
Mailing Address - Phone:503-667-1015
Mailing Address - Fax:503-667-0406
Practice Address - Street 1:24900 SE STARK ST STE 109
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3381
Practice Address - Country:US
Practice Address - Phone:503-667-1015
Practice Address - Fax:503-667-0406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR01794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCS0995OtherRAILROAD MEDICARE
ORR0000WCGLTMedicare PIN