MEDICARE: COUNTY OF POLK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	171M00000X	Case Manager/Care Coordinator
2	261QA0005X	Ambulatory Family Planning Facility
3	2083P0901X	Public Health & General Preventive Medicine Physician
4	261QP0905X	State or Local Public Health Clinic/Center

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710910781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTY OF POLK

Provider Business Mailing Address
First Line	:	182 SW ACADEMY STREET
Second Line	:	SUITE 302
City	:	DALLAS
State	:	OR
Zip	:	97338-1922
Country	:	US
Telephone Number	:	503-623-8175
Fax Number	:	503-831-3499

Provider Business Practice Location Address
First Line	:	182 SW ACADEMY STREET
Second Line	:	SUITE 302
City	:	DALLAS
State	:	OR
Zip	:	97338-1922
Country	:	US
Telephone Number	:	503-623-8175
Fax Number	:	503-831-3499

Authorized Official
Title or Position	:	ADMINISTRATIVE OFFICER
Name	:	MR. GREG P. HANSEN
Credential	:
Telephone Number	:	503-623-8173

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	06/23/2015

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Directions to “COUNTY OF POLK ” Practice Location

Language	Start Address	Practice Location

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