Provider Demographics
NPI:1336171198
Name:COLLINS, MICHAEL S (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:COLLINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 NW 22ND AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2900
Mailing Address - Country:US
Mailing Address - Phone:503-229-7353
Mailing Address - Fax:503-229-7255
Practice Address - Street 1:1130 NW 22ND AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2900
Practice Address - Country:US
Practice Address - Phone:503-229-7353
Practice Address - Fax:503-229-7255
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12861174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226977Medicaid
OR226977Medicaid
OROOWCKFYEMedicare ID - Type Unspecified