Provider Demographics
NPI:1265423818
Name:EAST PORTLAND PEDIATRIC CLINIC, P.C.
Entity type:Organization
Organization Name:EAST PORTLAND PEDIATRIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIFERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-255-3544
Mailing Address - Street 1:10000 SE MAIN ST
Mailing Address - Street 2:SUITE 30
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2448
Mailing Address - Country:US
Mailing Address - Phone:503-255-3544
Mailing Address - Fax:503-251-6827
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-255-3544
Practice Address - Fax:503-251-6827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR042309Medicaid