Provider Demographics
NPI:1588163844
Name:PEDIATRIC EVENING CARE, LLC
Entity type:Organization
Organization Name:PEDIATRIC EVENING CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRUCELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-905-3400
Mailing Address - Street 1:1510 DIVISION ST STE 280
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2550
Mailing Address - Country:US
Mailing Address - Phone:503-905-3400
Mailing Address - Fax:503-905-3399
Practice Address - Street 1:1510 DIVISION ST STE 280
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2550
Practice Address - Country:US
Practice Address - Phone:503-905-3400
Practice Address - Fax:503-905-3399
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC EVENING CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD162166208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD162166OtherMEDICAL LICENSE