MEDICARE: TODD GILLINGHAM MD LLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1801144985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TODD GILLINGHAM MD LLC

Provider Business Mailing Address
First Line	:	15160 NW LAIDLAW RD
Second Line	:	SUITE 100
City	:	PORTLAND
State	:	OR
Zip	:	97229-7707
Country	:	US
Telephone Number	:	503-582-8283
Fax Number	:	503-582-9004

Provider Business Practice Location Address
First Line	:	15160 NW LAIDLAW RD
Second Line	:	SUITE 100
City	:	PORTLAND
State	:	OR
Zip	:	97229-7707
Country	:	US
Telephone Number	:	503-582-8283
Fax Number	:	503-582-9004

Authorized Official
Title or Position	:	OWNER
Name	:	TODD GILLINGHAM
Credential	:	M.D.
Telephone Number	:	503-582-8283

Provider Enumeration Date	:	08/21/2012
Last Update Date	:	08/21/2012

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