Provider Demographics
NPI:1245312842
Name:HILLSBORO PEDIATRIC CLINIC LLC
Entity type:Organization
Organization Name:HILLSBORO PEDIATRIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPA/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:503-640-2757
Mailing Address - Street 1:445 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4084
Mailing Address - Country:US
Mailing Address - Phone:503-640-2757
Mailing Address - Fax:503-640-9753
Practice Address - Street 1:445 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4084
Practice Address - Country:US
Practice Address - Phone:503-640-2757
Practice Address - Fax:503-640-9753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023873000OtherBLUE CROSS GROUP ID
1245312842OtherNPI
R163532OtherPTAN
OR022706Medicaid
OR115396Medicare ID - Type UnspecifiedMEDICARE GROUP ID