Provider Demographics
NPI:1265517437
Name:CEDAR CREEK INTERNAL MEDICINE,PC
Entity type:Organization
Organization Name:CEDAR CREEK INTERNAL MEDICINE,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FANCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-280-4555
Mailing Address - Street 1:10200 SW EASTRIDGE ST
Mailing Address - Street 2:STE 205
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5064
Mailing Address - Country:US
Mailing Address - Phone:503-280-4555
Mailing Address - Fax:503-280-4559
Practice Address - Street 1:10200 SW EASTRIDGE ST
Practice Address - Street 2:STE 205
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5064
Practice Address - Country:US
Practice Address - Phone:503-280-4555
Practice Address - Fax:503-280-4559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR108054Medicare ID - Type UnspecifiedGROUP NUMBER