Healthcare Provider Details

I. General information

NPI: 1083638589
Provider Name (Legal Business Name): NORTHWEST PRIMARY CARE GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10024 SE 32ND AVE
MILWAUKIE OR
97222-6514
US

IV. Provider business mailing address

PO BOX 22075
MILWAUKIE OR
97269-2075
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-4988
  • Fax: 503-654-5666
Mailing address:
  • Phone: 503-659-4777
  • Fax: 503-652-5223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL WHITBECK
Title or Position: ADMINISTRATOR
Credential:
Phone: 503-659-4777