Provider Demographics
NPI:1932839776
Name:INTERSTATE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:INTERSTATE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGIUDICE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-339-7351
Mailing Address - Street 1:17221 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-1240
Mailing Address - Country:US
Mailing Address - Phone:503-760-0778
Mailing Address - Fax:503-760-0753
Practice Address - Street 1:17221 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-1240
Practice Address - Country:US
Practice Address - Phone:503-760-0778
Practice Address - Fax:503-760-0753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-14
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty