Provider Demographics
NPI:1295741759
Name:EISEN, GLENN MILES (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:MILES
Last Name:EISEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:9701 SW BARNES RD
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6772
Practice Address - Country:US
Practice Address - Phone:503-297-8081
Practice Address - Fax:503-292-6601
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD24716207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR299514Medicaid
WA1031219Medicaid
OR154643Medicare PIN