Healthcare Provider Details

I. General information

NPI: 1154336659
Provider Name (Legal Business Name): MARKUS CHARLES PAUL GROMPE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

6545 SW 34TH AVE
PORTLAND OR
97239-1077
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-5516
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberMD18061
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD18061
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: