Healthcare Provider Details

I. General information

NPI: 1922209832
Provider Name (Legal Business Name): OREGON CITY MEDICAL NW INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 MOLALLA AVE STE A&B
OREGON CITY OR
97045-2799
US

IV. Provider business mailing address

728 MOLALLA AVE STE A&B
OREGON CITY OR
97045-2799
US

V. Phone/Fax

Practice location:
  • Phone: 503-656-9030
  • Fax: 503-656-9026
Mailing address:
  • Phone: 503-656-9030
  • Fax: 503-656-9026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. DANIELLE L BLACKWELL
Title or Position: OWNER
Credential:
Phone: 503-656-9030