Healthcare Provider Details

I. General information

NPI: 1285667170
Provider Name (Legal Business Name): CHARLES EDWIN IRISH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18650 NW CORNELL RD SUITE 212
HILLSBORO OR
97124-9207
US

IV. Provider business mailing address

9155 SW BARNES RD SUITE 830
PORTLAND OR
97225-6625
US

V. Phone/Fax

Practice location:
  • Phone: 503-292-1103
  • Fax: 503-292-1433
Mailing address:
  • Phone: 503-292-1103
  • Fax: 503-292-1433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD09659
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: