Healthcare Provider Details

I. General information

NPI: 1083686554
Provider Name (Legal Business Name): SELLWOOD MEDICAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8332 SE 13TH AVE
PORTLAND OR
97202-7102
US

IV. Provider business mailing address

8332 SE 13TH AVE
PORTLAND OR
97202-7102
US

V. Phone/Fax

Practice location:
  • Phone: 503-595-9300
  • Fax: 503-233-1892
Mailing address:
  • Phone: 503-595-9300
  • Fax: 503-233-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD11101
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD06704
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberP83603
License Number StateOR

VIII. Authorized Official

Name: MORGAN MUNOZ
Title or Position: BUSINESS OFFICE SUPERVISOR
Credential:
Phone: 503-595-9300