Healthcare Provider Details

I. General information

NPI: 1780021899
Provider Name (Legal Business Name): GRAPEVINE WOMENS HEALTH AND GYNECOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5880 NE CORNELL RD STE C
HILLSBORO OR
97124-9075
US

IV. Provider business mailing address

13124 NW OLD GERMANTOWN RD
PORTLAND OR
97231-2711
US

V. Phone/Fax

Practice location:
  • Phone: 503-781-8846
  • Fax:
Mailing address:
  • Phone: 503-781-8846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number23173
License Number StateOR

VIII. Authorized Official

Name: DR. NICOLA ROTBERG
Title or Position: MANAGER
Credential: MD
Phone: 503-781-8846