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General NPI Number Information
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NPI Number | 1780021899
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Entity Type | Organization
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Legal Business Name | GRAPEVINE WOMENS HEALTH AND GYNECOLOGY, LLC
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Dates
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Enumeration Date | 05/30/2013
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Last Update Date | 06/05/2013
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Provider Practice Location Address
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Address Line | 5880 NE CORNELL RD STE C
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City | HILLSBORO
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State | OR
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Zip | 97124-9075
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Country | US
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Telephone | 503-781-8846
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Fax |
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Provider Business Mailing Address
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Address Line | 13124 NW OLD GERMANTOWN RD
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City | PORTLAND
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State | OR
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Zip | 97231-2711
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Country | US
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Telephone | 503-781-8846
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. NICOLA ROTBERG
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Credential | MD
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Telephone | 503-781-8846
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | 23173
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License Number State | OR
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