Provider Demographics
NPI:1306802269
Name:RYDLUND, KELLY WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:WILLIAM
Last Name:RYDLUND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1508 DIVISION ST
Practice Address - Street 2:SUITE 115
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1582
Practice Address - Country:US
Practice Address - Phone:503-656-0601
Practice Address - Fax:503-656-1389
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25603207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2038805Medicaid
OR023154Medicaid
131493Medicare ID - Type Unspecified
WA2038805Medicaid
OR023154Medicaid
OR175994Medicare PIN