Healthcare Provider Details

I. General information

NPI: 1043245830
Provider Name (Legal Business Name): SUZANNE MCCLINTICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUZANNE M DINSMORE

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

891 23RD ST NE
SALEM OR
97301
US

IV. Provider business mailing address

891 23RD ST NE
SALEM OR
97301
US

V. Phone/Fax

Practice location:
  • Phone: 503-364-2181
  • Fax: 503-364-0364
Mailing address:
  • Phone: 503-364-2181
  • Fax: 503-364-0364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13517
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier207050
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: