Healthcare Provider Details

I. General information

NPI: 1255513701
Provider Name (Legal Business Name): GRESHAM WOMEN'S HEALTHCARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 NE DIVISION ST STE 202
GRESHAM OR
97030-5859
US

IV. Provider business mailing address

2150 NE DIVISION ST STE 202
GRESHAM OR
97030-5859
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-4545
  • Fax: 503-666-3298
Mailing address:
  • Phone: 503-667-4545
  • Fax: 503-666-3298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDO17065
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier269959
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: DR. B. EDWARD YANKE
Title or Position: OWNER
Credential: D.O.
Phone: 503-667-4545