Healthcare Provider Details

I. General information

NPI: 1376084632
Provider Name (Legal Business Name): ADRIAN ANTHONY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2017
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 NW BURNSIDE RD
GRESHAM OR
97030-3739
US

IV. Provider business mailing address

689 NW BURNSIDE RD
GRESHAM OR
97030-3739
US

V. Phone/Fax

Practice location:
  • Phone: 503-382-8100
  • Fax:
Mailing address:
  • Phone: 503-382-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD209904
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: