Healthcare Provider Details

I. General information

NPI: 1356395412
Provider Name (Legal Business Name): CHARLES KENNETH LINEHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92659 HIGHWAY 202
ASTORIA OR
97103-8522
US

IV. Provider business mailing address

92659 HIGHWAY 202
ASTORIA OR
97103-8522
US

V. Phone/Fax

Practice location:
  • Phone: 503-325-3902
  • Fax: 503-325-3902
Mailing address:
  • Phone: 503-325-3902
  • Fax: 503-325-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD 05254
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier239848
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: