MEDICARE: URGENT CARE NW GRESHAM 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	261QU0200X	Urgent Care Clinic/Center	MD14769	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336128321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	URGENT CARE NW GRESHAM PC

Provider Business Mailing Address
First Line	:	PO BOX 647
Second Line	:
City	:	GRESHAM
State	:	OR
Zip	:	97030-0167
Country	:	US
Telephone Number	:	503-666-5050
Fax Number	:	503-666-7410

Provider Business Practice Location Address
First Line	:	2850 SE POWELL VALLEY RD
Second Line	:
City	:	GRESHAM
State	:	OR
Zip	:	97080
Country	:	US
Telephone Number	:	503-666-5050
Fax Number	:	503-666-7410

Authorized Official
Title or Position	:	SUPERVISOR
Name	:	MRS. MELISSA L JARCHOW
Credential	:
Telephone Number	:	503-666-5050

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	08/10/2010

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