Healthcare Provider Details

I. General information

NPI: 1417167834
Provider Name (Legal Business Name): FOREST GROVE PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 MOUNTAIN VIEW LN SUITE 200
FOREST GROVE OR
97116-2382
US

IV. Provider business mailing address

1911 MOUNTAIN VIEW LN SUITE 200
FOREST GROVE OR
97116-2382
US

V. Phone/Fax

Practice location:
  • Phone: 503-359-1930
  • Fax: 503-359-1985
Mailing address:
  • Phone: 503-359-1930
  • Fax: 503-359-1985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. KATHERINE ROSE LONG
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 503-359-1930