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NPI Code Detail

MEDICARE: NORTHWEST DERMATOLOGY & LASER CLINIC PC

MEDICARE: NORTHWEST DERMATOLOGY & LASER 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
1207N00000XDermatology PhysicianMD14681OR

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1DD5356OTHERORRAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1376571364
Entity Type Code : Organization
Provider Name (Legal Business Name) : NORTHWEST DERMATOLOGY & LASER CLINIC PC
Provider Business Mailing Address
First Line : PO BOX 23200
Second Line :
City : PORTLAND
State : OR
Zip : 97281-3200
Country : US
Telephone Number : 503-968-4620
Fax Number : 503-968-2779
Provider Business Practice Location Address
First Line : 1130 NW 22ND AVE STE 330
Second Line :
City : PORTLAND
State : OR
Zip : 97210-2970
Country : US
Telephone Number : 503-295-2366
Fax Number : 503-295-3065
Authorized Official
Title or Position : PRESIDENT
Name : DR. BERT G TAVELLI
Credential : MD
Telephone Number : 503-295-2366
Provider Enumeration Date : 06/29/2006
Last Update Date : 06/01/2016

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Directions to “NORTHWEST DERMATOLOGY & LASER CLINIC PC ” Practice Location

Language Start Address Practice Location
These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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