Healthcare Provider Details

I. General information

NPI: 1245472430
Provider Name (Legal Business Name): BRYAN SCOTT CHILD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 OAK ST SE
SALEM OR
97301-3905
US

IV. Provider business mailing address

22762 SW 106TH AVE
TUALATIN OR
97062-7385
US

V. Phone/Fax

Practice location:
  • Phone: 509-987-6774
  • Fax:
Mailing address:
  • Phone: 509-987-6774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60279400
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD60279400
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD184925
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier1245472430
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
Identifier025904
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerKRMC L&I GROUP NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: