=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922304302
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTSIDE ALLERGY ASTHMA & GENERAL INTERNAL MEDICINE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2011
-----------------------------------------------------
Last Update Date | 02/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2850 SE POWELL BLVD SUITE 206
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97080-1494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-666-5025
-----------------------------------------------------
Fax | 503-666-5795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2850 SE POWELL BLVD SUITE 206
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97080-1494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-666-5025
-----------------------------------------------------
Fax | 503-666-5795
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. AUSTIN UNDERWOOD SARGENT
-----------------------------------------------------
Credential | M.D. PHD
-----------------------------------------------------
Telephone | 503-666-5025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | MD21072
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------