MEDICARE: MT. TABOR FAMILY MEDICAL 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1659468080
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MT. TABOR FAMILY MEDICAL GROUP, PC

Provider Business Mailing Address
First Line	:	5919 SE BELMONT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97215-1925
Country	:	US
Telephone Number	:	503-234-7366
Fax Number	:	503-234-8928

Provider Business Practice Location Address
First Line	:	5919 SE BELMONT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97215-1925
Country	:	US
Telephone Number	:	503-234-7366
Fax Number	:	503-234-8928

Authorized Official
Title or Position	:	CLINIC MANAGER
Name	:	MRS. LORI E NIES
Credential	:
Telephone Number	:	503-234-7366

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	03/01/2013

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