Healthcare Provider Details

I. General information

NPI: 1881746899
Provider Name (Legal Business Name): ROBERT CONOVER MACAULEY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/21/2022
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

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

V. Phone/Fax

Practice location:
  • Phone: 503-494-8417
  • Fax: 503-494-4455
Mailing address:
  • Phone: 503-494-8417
  • Fax: 503-494-4455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0420010479
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number182551
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: