Provider Demographics
NPI:1174710990
Name:INTERNAL MEDICINE ASSOCIATES OF PORTLAND, LLC
Entity type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF PORTLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:F.
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-853-8631
Mailing Address - Street 1:10373 NE HANCOCK ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3873
Mailing Address - Country:US
Mailing Address - Phone:503-853-8631
Mailing Address - Fax:503-853-8636
Practice Address - Street 1:10373 NE HANCOCK ST
Practice Address - Street 2:SUITE 115
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3873
Practice Address - Country:US
Practice Address - Phone:503-853-8631
Practice Address - Fax:503-853-8636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08175207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
139365OtherMEDICARE PTAN
139365OtherMEDICARE PTAN