Provider Demographics
NPI:1134242506
Name:PORTLAND VETERANS AFFAIRS MEDICAL CENTER
Entity type:Organization
Organization Name:PORTLAND VETERANS AFFAIRS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPENDENT CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-220-8262
Mailing Address - Street 1:5430 SW CAMERON RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-1754
Mailing Address - Country:US
Mailing Address - Phone:503-293-0222
Mailing Address - Fax:
Practice Address - Street 1:5430 SW CAMERON RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221
Practice Address - Country:US
Practice Address - Phone:503-293-0222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR282N00000X282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital