Provider Demographics
NPI:1780890038
Name:BRAIN REHABILITATION MEDICINE
Entity type:Organization
Organization Name:BRAIN REHABILITATION MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:LAURE
Authorized Official - Last Name:ERB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-296-0918
Mailing Address - Street 1:1815 SW MARLOW AVE
Mailing Address - Street 2:110
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5185
Mailing Address - Country:US
Mailing Address - Phone:503-296-0918
Mailing Address - Fax:503-296-6158
Practice Address - Street 1:1815 SW MARLOW AVE
Practice Address - Street 2:110
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5185
Practice Address - Country:US
Practice Address - Phone:503-296-0918
Practice Address - Fax:503-296-6158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD167212081H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR021191Medicaid
ORE60597Medicare UPIN
OR021191Medicaid