Provider Demographics
NPI:1396754560
Name:WOMEN'S CLINIC PC
Entity type:Organization
Organization Name:WOMEN'S CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARYKAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-249-5491
Mailing Address - Street 1:501 N GRAHAM ST
Mailing Address - Street 2:SUITE 525
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1654
Mailing Address - Country:US
Mailing Address - Phone:503-249-5454
Mailing Address - Fax:503-249-5498
Practice Address - Street 1:501 N GRAHAM ST
Practice Address - Street 2:SUITE 525
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1654
Practice Address - Country:US
Practice Address - Phone:503-249-5454
Practice Address - Fax:503-249-5498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-06
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR064688Medicaid
OOOOWCHHFMedicare ID - Type Unspecified