Healthcare Provider Details

I. General information

NPI: 1922304302
Provider Name (Legal Business Name): EASTSIDE ALLERGY ASTHMA & GENERAL INTERNAL MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 SE POWELL BLVD SUITE 206
GRESHAM OR
97080-1494
US

IV. Provider business mailing address

2850 SE POWELL BLVD SUITE 206
GRESHAM OR
97080-1494
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-5025
  • Fax: 503-666-5795
Mailing address:
  • Phone: 503-666-5025
  • Fax: 503-666-5795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberMD21072
License Number StateOR

VIII. Authorized Official

Name: DR. AUSTIN UNDERWOOD SARGENT
Title or Position: PRESIDENT/OWNER
Credential: M.D. PHD
Phone: 503-666-5025