Healthcare Provider Details

I. General information

NPI: 1528105194
Provider Name (Legal Business Name): KEITH PHILLIP CROSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
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

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

V. Phone/Fax

Practice location:
  • Phone: 503-494-7551
  • Fax: 503-494-4997
Mailing address:
  • Phone: 503-494-7551
  • Fax: 503-494-4997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number294757-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD214291
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number40990
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number294757-1
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberMD214291
License Number StateOR
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD214291
License Number StateOR
# 7
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40990
License Number StateKY
# 8
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40990
License Number StateKY
# 9
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number294757-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: