Provider Demographics
NPI:1215910302
Name:PORTLAND ADVENTIST MEDICAL CENTER
Entity type:Organization
Organization Name:PORTLAND ADVENTIST MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-251-6842
Mailing Address - Street 1:PO BOX 888918
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90088-8918
Mailing Address - Country:US
Mailing Address - Phone:503-261-6085
Mailing Address - Fax:
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:SUITE 116
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216
Practice Address - Country:US
Practice Address - Phone:503-251-6354
Practice Address - Fax:503-251-6286
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTLAND ADVENTIST MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-22
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14 1127207PE0005X, 207Q00000X, 207R00000X, 207RC0000X, 207RG0100X, 207RH0002X, 207RP1001X, 207RR0500X, 2083X0100X, 2084P0800X, 208M00000X, 207RH0002X
207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0127633OtherWA LABOR & INDUSTRIES
WA0201918OtherWA L&I (OCCMED CLINIC)
WACH2083OtherRAILROAD MEDICARE WA CLIN
ORCI4927OtherRAILROAD MEDICARE OR CLIN
OR0000ZBBVVMedicare PIN
WACH2083OtherRAILROAD MEDICARE WA CLIN
WA0201918OtherWA L&I (OCCMED CLINIC)