Healthcare Provider Details

I. General information

NPI: 1831253673
Provider Name (Legal Business Name): POPLAR HILL FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22490 SW MOUNTAIN RD
WEST LINN OR
97068-9619
US

IV. Provider business mailing address

22490 SW MOUNTAIN RD
WEST LINN OR
97068-9619
US

V. Phone/Fax

Practice location:
  • Phone: 503-638-8218
  • Fax: 503-638-9698
Mailing address:
  • Phone: 503-638-8218
  • Fax: 503-638-9698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD08471
License Number StateOR

VIII. Authorized Official

Name: ROBERT BASTIAN WAGNER
Title or Position: PRESIDENT
Credential: MD
Phone: 503-638-8218