Provider Demographics
NPI:1255513701
Name:GRESHAM WOMEN'S HEALTHCARE, PC
Entity type:Organization
Organization Name:GRESHAM WOMEN'S HEALTHCARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:B. EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:YANKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-667-4545
Mailing Address - Street 1:2150 NE DIVISION ST STE 202
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5859
Mailing Address - Country:US
Mailing Address - Phone:503-667-4545
Mailing Address - Fax:503-666-3298
Practice Address - Street 1:2150 NE DIVISION ST STE 202
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5859
Practice Address - Country:US
Practice Address - Phone:503-667-4545
Practice Address - Fax:503-666-3298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO17065207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269959Medicaid
OR113434Medicare PIN