Provider Demographics
NPI:1366745655
Name:PORTLAND GYNECOLOGIC ONCOLOGY, PC
Entity type:Organization
Organization Name:PORTLAND GYNECOLOGIC ONCOLOGY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:REDDOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-297-8700
Mailing Address - Street 1:9155 SW BARNES RD STE 416
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6631
Mailing Address - Country:US
Mailing Address - Phone:503-297-8700
Mailing Address - Fax:503-297-2201
Practice Address - Street 1:9155 SW BARNES RD STE 416
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6631
Practice Address - Country:US
Practice Address - Phone:503-297-8700
Practice Address - Fax:503-297-2201
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTLAND GYNECOLOGIC ONCOLOGY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16638174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR024660Medicaid
OR069021000OtherBC/BS OREGON
OR069021000OtherBC/BS OREGON
OR024660Medicaid