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General NPI Number Information
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NPI Number | 1134204340
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Entity Type | Organization
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Legal Business Name | GRESHAM INTERNAL MEDICINE CLINIC
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Dates
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Enumeration Date | 10/26/2006
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Last Update Date | 12/11/2008
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Provider Practice Location Address
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Address Line | 24900 SE STARK ST STE 109
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City | GRESHAM
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State | OR
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Zip | 97030-3381
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Country | US
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Telephone | 503-667-1015
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Fax | 503-667-0406
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Provider Business Mailing Address
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Address Line | PO BOX 23200
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City | PORTLAND
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State | OR
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Zip | 97281-3200
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Country | US
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Telephone | 503-667-1015
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Fax | 503-667-0406
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Authorized Official
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Title or Position | OWNER/PARTNER
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Name | DR. JOHN M CUSTIS
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Credential | MD
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Telephone | 503-667-1015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 01794
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License Number State | OR
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