Provider Demographics
NPI:1629899448
Name:MATTHEW'S FAMILY PRIMARY CARE, LLC
Entity type:Organization
Organization Name:MATTHEW'S FAMILY PRIMARY CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BERHANU
Authorized Official - Middle Name:EJIGU
Authorized Official - Last Name:KEDEDA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, AGACNP, DNP
Authorized Official - Phone:678-793-8808
Mailing Address - Street 1:18514 SE WILMOT ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-6426
Mailing Address - Country:US
Mailing Address - Phone:678-793-8808
Mailing Address - Fax:
Practice Address - Street 1:18514 SE WILMOT ST UNIT B
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-6426
Practice Address - Country:US
Practice Address - Phone:678-793-8808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-23
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty