Provider Demographics
NPI:1457555666
Name:OSTEOPATHIC MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:OSTEOPATHIC MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:KEIM
Authorized Official - Last Name:GOERING
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-236-2303
Mailing Address - Street 1:6564 SE LAKE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2138
Mailing Address - Country:US
Mailing Address - Phone:503-236-2303
Mailing Address - Fax:503-236-2614
Practice Address - Street 1:6564 SE LAKE RD STE 101
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2138
Practice Address - Country:US
Practice Address - Phone:503-236-2303
Practice Address - Fax:503-236-2614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR433453204D00000X, 207Q00000X, 208100000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130308Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER