Healthcare Provider Details

I. General information

NPI: 1568592913
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF GRESHAM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 NE DIVISION ST STE 103
GRESHAM OR
97030-5858
US

IV. Provider business mailing address

2150 NE DIVISION ST STE 103
GRESHAM OR
97030-5858
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-4200
  • Fax: 503-666-0566
Mailing address:
  • Phone: 503-661-4200
  • Fax: 503-666-0566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0659871-9
License Number StateOR

VIII. Authorized Official

Name: NORMAN T EKI
Title or Position: PRESIDENT
Credential: MD
Phone: 503-661-4200