MEDICARE: COUNTY OF POLK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	163WP0808X	Psychiatric/Mental Health Registered Nurse
3	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427081470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTY OF POLK

Provider Business Mailing Address
First Line	:	182 SW ACADEMY
Second Line	:	POLK COUNTY MEDICAL HEALTH SUITE 310
City	:	DALLAS
State	:	OR
Zip	:	97338-1922
Country	:	US
Telephone Number	:	503-623-9317
Fax Number	:	503-623-2731

Provider Business Practice Location Address
First Line	:	182 SW ACADEMY
Second Line	:	SUITE 304
City	:	DALLAS
State	:	OR
Zip	:	97338-1922
Country	:	US
Telephone Number	:	503-623-9289
Fax Number	:	503-831-1726

Authorized Official
Title or Position	:	POLK COUNTY ADMINISTRATIVE OFFICER
Name	:	MR. GREG P HANSEN
Credential	:
Telephone Number	:	503-623-8173

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	09/05/2007

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Directions to “COUNTY OF POLK ” Practice Location

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