Provider Demographics
NPI:1770926941
Name:GENERATIONS FAMILY MEDICINE, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:GENERATIONS FAMILY MEDICINE, PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THANHLONG
Authorized Official - Middle Name:DUC
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-703-1500
Mailing Address - Street 1:8106 NE WASCO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-6737
Mailing Address - Country:US
Mailing Address - Phone:503-255-8258
Mailing Address - Fax:503-252-1668
Practice Address - Street 1:8106 NE WASCO ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-6737
Practice Address - Country:US
Practice Address - Phone:503-255-8258
Practice Address - Fax:503-252-1668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-08
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
ORMD28383261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241669Medicaid
ORR142499OtherMEDICARE PROVIDER NUMBER