Healthcare Provider Details

I. General information

NPI: 1306802269
Provider Name (Legal Business Name): KELLY WILLIAM RYDLUND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 DIVISION ST SUITE 115
OREGON CITY OR
97045-1582
US

IV. Provider business mailing address

541 NE 20TH AVE STE 225
PORTLAND OR
97232-2895
US

V. Phone/Fax

Practice location:
  • Phone: 503-656-0601
  • Fax: 503-656-1389
Mailing address:
  • Phone: 503-963-2801
  • Fax: 503-963-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD25603
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: