Provider Demographics
NPI:1174592190
Name:MIGCHELBRINK, SUZANNE L (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:L
Last Name:MIGCHELBRINK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 NW LOVEJOY ST STE 505
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5103
Mailing Address - Country:US
Mailing Address - Phone:503-242-9850
Mailing Address - Fax:503-226-3539
Practice Address - Street 1:19250 SW 65TH AVE
Practice Address - Street 2:STE 110
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7452
Practice Address - Country:US
Practice Address - Phone:503-692-1205
Practice Address - Fax:503-692-1207
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21844207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287446Medicaid
OR109925Medicare ID - Type Unspecified
OR287446Medicaid