Provider Demographics
NPI:1154526341
Name:A BROOKE BENZ
Entity type:Organization
Organization Name:A BROOKE BENZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN & SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:A BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-629-7500
Mailing Address - Street 1:1960 NW 167TH PL STE 205
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4804
Mailing Address - Country:US
Mailing Address - Phone:503-629-7500
Mailing Address - Fax:503-629-7505
Practice Address - Street 1:1960 NW 167TH PL STE 205
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4804
Practice Address - Country:US
Practice Address - Phone:503-629-7500
Practice Address - Fax:503-629-7505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14378174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR132769Medicare ID - Type Unspecified
ORC92194Medicare UPIN
OR132449Medicare ID - Type UnspecifiedMCA ID
OK132448Medicare ID - Type UnspecifiedMCA GROUP
OR132578Medicare UPIN