Healthcare Provider Details

I. General information

NPI: 1104834969
Provider Name (Legal Business Name): LEGACY MOUNT HOOD MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24800 SE STARK ST
GRESHAM OR
97030-3378
US

IV. Provider business mailing address

PO BOX 10768
PORTLAND OR
97296-0768
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1233
  • Fax: 503-674-1647
Mailing address:
  • Phone: 503-674-1233
  • Fax: 503-674-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number14 1337
License Number StateOR

VIII. Authorized Official

Name: PAMELA S. VUKOVICH
Title or Position: SR. VP/CFO
Credential:
Phone: 503-415-5370