Provider Demographics
NPI:1952355893
Name:CRAIG HERTLER MD LLC
Entity type:Organization
Organization Name:CRAIG HERTLER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:K
Authorized Official - Last Name:HERTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-222-3638
Mailing Address - Street 1:2222 NW LOVEJOY
Mailing Address - Street 2:#607
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-222-3638
Mailing Address - Fax:
Practice Address - Street 1:2222 NW LOVEJOY
Practice Address - Street 2:#607
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-222-3638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14722174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR012893Medicaid
ORE62339Medicare UPIN
OR012893Medicaid