MEDICARE: PEDIATRIC EVENING CARE, LLC

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	208000000X	Pediatrics Physician	MD162166	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MD162166	OTHER	OR	MEDICAL LICENSE

General Provider Information

NPI Number	:	1588163844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC EVENING CARE, LLC

Provider Business Mailing Address
First Line	:	1510 DIVISION ST STE 280
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-2550
Country	:	US
Telephone Number	:	503-905-3400
Fax Number	:	503-905-3399

Provider Business Practice Location Address
First Line	:	1510 DIVISION ST STE 280
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-2550
Country	:	US
Telephone Number	:	503-905-3400
Fax Number	:	503-905-3399

Authorized Official
Title or Position	:	CEO
Name	:	CHRISTINA M GRUCELLA
Credential	:	MD
Telephone Number	:	503-905-3400

Provider Enumeration Date	:	02/01/2018
Last Update Date	:	02/01/2018

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