Healthcare Provider Details

I. General information

NPI: 1629103361
Provider Name (Legal Business Name): WILLAMETTE FALLS PEDIATRIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 DIVISION ST SUITE 280
OREGON CITY OR
97045-1581
US

IV. Provider business mailing address

1510 DIVISION ST SUITE 280
OREGON CITY OR
97045-1581
US

V. Phone/Fax

Practice location:
  • Phone: 503-905-3400
  • Fax: 503-905-3399
Mailing address:
  • Phone: 503-905-3400
  • Fax: 503-905-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD16083
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier028484
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier820444000
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name: CHRISTINA M GRUCELLA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 503-905-3400