Provider Demographics
NPI:1770776387
Name:PROVIDENCE PORLAND MEDICAL CENTER
Entity type:Organization
Organization Name:PROVIDENCE PORLAND MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RN/NURSE PRACTITIONER STUDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:EELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1503-215-6150
Mailing Address - Street 1:312 ENGLE AVE
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-9138
Mailing Address - Country:US
Mailing Address - Phone:150-335-1019
Mailing Address - Fax:
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09000464RN313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility