Provider Demographics
NPI:1831264357
Name:PACIFIC FAMILY MEDICAL CENTER LLC
Entity type:Organization
Organization Name:PACIFIC FAMILY MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-540-7477
Mailing Address - Street 1:1285 LIBERTY ST SE
Mailing Address - Street 2:PO BOX 31
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4243
Mailing Address - Country:US
Mailing Address - Phone:503-540-7477
Mailing Address - Fax:
Practice Address - Street 1:1285 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4243
Practice Address - Country:US
Practice Address - Phone:503-540-7477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25908207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278109Medicaid
OR133852Medicare ID - Type Unspecified
OR278109Medicaid