Provider Demographics
NPI:1386983922
Name:GEORGE M DOUGLASS MD PC
Entity type:Organization
Organization Name:GEORGE M DOUGLASS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:503-502-3989
Mailing Address - Street 1:9445 SW LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6634
Mailing Address - Country:US
Mailing Address - Phone:503-352-1313
Mailing Address - Fax:503-352-1314
Practice Address - Street 1:9445 SW LOCUST ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6634
Practice Address - Country:US
Practice Address - Phone:503-352-1313
Practice Address - Fax:503-352-1314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22100207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240052Medicaid