Provider Demographics
NPI:1285885632
Name:KISHORE G PATHIAL MD PC
Entity type:Organization
Organization Name:KISHORE G PATHIAL MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KISHORE
Authorized Official - Middle Name:G
Authorized Official - Last Name:PATHIAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-472-5163
Mailing Address - Street 1:2397 NE CUMULUS AVE
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6255
Mailing Address - Country:US
Mailing Address - Phone:503-472-5163
Mailing Address - Fax:503-472-3320
Practice Address - Street 1:2397 NE CUMULUS AVE
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6255
Practice Address - Country:US
Practice Address - Phone:503-472-5163
Practice Address - Fax:503-472-3320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6952791261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR055884Medicaid
R119483Medicare UPIN
ORR159165Medicare UPIN
R117632Medicare UPIN