=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457638884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YALE S. POPOWICH, M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2011
-----------------------------------------------------
Last Update Date | 07/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 NW 14TH AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97209-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-546-1664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 NW 14TH AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97209-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-546-1664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | YALE S POPOWICH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 503-546-1664
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | MD266661
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------