MEDICARE: MAPLE STREET CLINIC, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R0000WCBCC	OTHER	OR	MEDICARE PTIN

General Provider Information

NPI Number	:	1225066194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE STREET CLINIC, PC

Provider Business Mailing Address
First Line	:	1825 MAPLE ST
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1939
Country	:	US
Telephone Number	:	503-357-2136
Fax Number	:	503-359-5479

Provider Business Practice Location Address
First Line	:	1825 MAPLE ST
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1939
Country	:	US
Telephone Number	:	503-357-2136
Fax Number	:	503-359-5479

Authorized Official
Title or Position	:	CLINIC ADMINISTRATOR
Name	:	MR. JOHN DAHLQUIST
Credential	:
Telephone Number	:	503-357-2136

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	01/10/2013

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Directions to “MAPLE STREET CLINIC, PC ” Practice Location

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