Provider Demographics
NPI:1124507827
Name:PORTLAND FOOT AND ANKLE INSTITUTE, LLC
Entity type:Organization
Organization Name:PORTLAND FOOT AND ANKLE INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:GENTILE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-536-3074
Mailing Address - Street 1:10690 NE CORNELL RD STE 212
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-9224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12672 NW BARNES RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-6191
Practice Address - Country:US
Practice Address - Phone:503-336-0169
Practice Address - Fax:503-352-4583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00371213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty