Provider Demographics
NPI:1063584217
Name:ELLERBROOK, RANDY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LEE
Last Name:ELLERBROOK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9155 SW BARNES RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6625
Mailing Address - Country:US
Mailing Address - Phone:503-445-3235
Mailing Address - Fax:503-790-2293
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:SUITE 205
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-297-5581
Practice Address - Fax:503-297-1421
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD08564207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR055715Medicaid
OR110104202OtherRAILROAD MEDICARE/PALMETT
OR003335013OtherREGENCE BLUE CROSS OF OR
OR00WCRCYAMedicare ID - Type Unspecified
OR055715Medicaid