Healthcare Provider Details

I. General information

NPI: 1386647147
Provider Name (Legal Business Name): ANGELA KALISIAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 N BROADWAY ST
PORTLAND OR
97227-1800
US

IV. Provider business mailing address

265 N BROADWAY ST
PORTLAND OR
97227-1800
US

V. Phone/Fax

Practice location:
  • Phone: 503-280-1223
  • Fax: 503-528-5252
Mailing address:
  • Phone: 503-280-1223
  • Fax: 503-528-5252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD17578
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberMD17578
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: