Provider Demographics
NPI:1811140130
Name:NORTHEAST MEDICAL CONSULTANTS, PC
Entity type:Organization
Organization Name:NORTHEAST MEDICAL CONSULTANTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CODINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-493-9730
Mailing Address - Street 1:4317 NE TILLAMOOK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1315
Mailing Address - Country:US
Mailing Address - Phone:503-493-9730
Mailing Address - Fax:
Practice Address - Street 1:4317 NE TILLAMOOK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1315
Practice Address - Country:US
Practice Address - Phone:503-493-9730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR215193-92261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR132542Medicare PIN
ORR132541Medicare PIN
ORU53584Medicare UPIN