Healthcare Provider Details

I. General information

NPI: 1366488090
Provider Name (Legal Business Name): OREGON PEDIATRICS NE PORTLAND PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 NE HOYT ST STE B55
PORTLAND OR
97213-2957
US

IV. Provider business mailing address

5050 NE HOYT ST STE B55
PORTLAND OR
97213-2957
US

V. Phone/Fax

Practice location:
  • Phone: 503-233-5393
  • Fax: 503-659-8984
Mailing address:
  • Phone: 503-233-5393
  • Fax: 503-659-8984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. RUPA KIRIT SHAH
Title or Position: CO OWNER & MEDICAL DIRECTOR
Credential: MD
Phone: 503-659-1694