Healthcare Provider Details

I. General information

NPI: 1598816605
Provider Name (Legal Business Name): GREGORY DAVID EMMERICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 NE DIVISION ST SUITE103
GRESHAM OR
97030-5813
US

IV. Provider business mailing address

2150 NE DIVISION ST SUITE103
GRESHAM OR
97030-5813
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 NumberMD15970
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: