MEDICARE: CHRISTINA MARIE GRUCELLA MD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	MD16083	OR

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	:	1528073020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA MARIE GRUCELLA MD

Provider Business Mailing Address
First Line	:	1240 SE 56TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97215-2706
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1510 DIVISION ST STE 280
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-2550
Country	:	US
Telephone Number	:	503-905-3400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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