Provider Demographics
NPI:1942252168
Name:BLIVEN, MATTHEW J (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:BLIVEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 SE STRATUS AVE
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128
Mailing Address - Country:US
Mailing Address - Phone:503-435-6441
Mailing Address - Fax:503-434-6290
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128
Practice Address - Country:US
Practice Address - Phone:503-435-6441
Practice Address - Fax:503-434-6445
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR082008Medicaid
08WCBCLEMedicare ID - Type Unspecified
OR082008Medicaid
R08WCBCLEMedicare PIN