Provider Demographics
NPI:1255364972
Name:MICHAELSON, ELLEN MARION (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARION
Last Name:MICHAELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 NW LOVEJOY ST STE 510
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:503-274-0045
Mailing Address - Fax:
Practice Address - Street 1:2222 NW LOVEJOY ST STE 510
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5103
Practice Address - Country:US
Practice Address - Phone:503-274-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD018281207RH0000X
ORMD18281207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORA002OtherTRICARE
OR057039OtherOMAP
OR804692001OtherBLUE CROSS
OR113811Medicare ID - Type Unspecified
ORE20424Medicare UPIN