Provider Demographics
NPI:1205091394
Name:SAMUEL V BARTHOLOMEW MD PC
Entity type:Organization
Organization Name:SAMUEL V BARTHOLOMEW MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:BARTHOLOMEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:503-292-9737
Mailing Address - Street 1:3439 NE SANDY BLVD
Mailing Address - Street 2:PMB 375
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1959
Mailing Address - Country:US
Mailing Address - Phone:503-284-8841
Mailing Address - Fax:503-282-3302
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:SUITE 532
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-292-9737
Practice Address - Fax:503-292-9680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24703208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022461Medicaid