Healthcare Provider Details

I. General information

NPI: 1801982764
Provider Name (Legal Business Name): KENNETH G PIPPUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9427 SW BARNES RD STE 395
PORTLAND OR
97225-6652
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-216-6050
  • Fax: 503-216-8658
Mailing address:
  • Phone: 503-215-6494
  • Fax: 503-215-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number41464
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberMD152536
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: