MEDICARE: SUNSET FAMILY PRACTICE GROUP 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	207R00000X	Internal Medicine Physician
2	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	141978	OTHER	OR	PTAN
2	1508809781	OTHER	OR	NPI
3	38D0621672	OTHER		CLIA
4	11896	OTHER	OR	PTAN
5	1437190741	OTHER	OR	NPI
6	DOWCQKWB	OTHER	OR	PTAN
7	1912014317	OTHER	OR	NPI
8	1841236924	OTHER	OR	NPI
9	1891736104	OTHER	OR	NPI
10	DOWCQKWC	OTHER	OR	PTAN
11	R00WCQKWD	OTHER	OR	PTAN

General Provider Information

NPI Number	:	1568408680
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNSET FAMILY PRACTICE GROUP PC

Provider Business Mailing Address
First Line	:	12400 NW CORNELL RD
Second Line	:	P.O. BOX 2767
City	:	PORTLAND
State	:	OR
Zip	:	97229-5616
Country	:	US
Telephone Number	:	503-626-0939
Fax Number	:	503-626-6161

Provider Business Practice Location Address
First Line	:	12400 NW CORNELL RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97229-5616
Country	:	US
Telephone Number	:	503-626-0939
Fax Number	:	503-626-6161

Authorized Official
Title or Position	:	LEAD PHYSICIAN
Name	:	MR. VIC KRISCIUNAS
Credential	:	MD
Telephone Number	:	503-626-0939

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	07/27/2010

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Directions to “SUNSET FAMILY PRACTICE GROUP PC ” Practice Location

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