Provider Demographics
NPI:1336596113
Name:AT HOME PRIMARY CARE
Entity type:Organization
Organization Name:AT HOME PRIMARY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:503-358-7908
Mailing Address - Street 1:PO BOX 945
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-0103
Mailing Address - Country:US
Mailing Address - Phone:503-344-6717
Mailing Address - Fax:503-345-9867
Practice Address - Street 1:511 MAIN ST
Practice Address - Street 2:SUITE 112
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1830
Practice Address - Country:US
Practice Address - Phone:503-344-6717
Practice Address - Fax:503-345-9867
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOUSECALL MEDICAL SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200650008NP261QP2300X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR243056Medicaid
OR200650008NPOtherNP LICENSE
ORR178969OtherMEDICARE ID INDIV
OR1932154366OtherNPI INDIV
OR500678021Medicaid
OR1093053431OtherNPI GROUP HMS
ORR178970OtherMEDICARE ID GROUP
ORR178970OtherMEDICARE ID GROUP
OR101558Medicare PIN