Provider Demographics
NPI:1912241746
Name:PORTLAND PREVENTIVE CARDIOLOGY LLC
Entity type:Organization
Organization Name:PORTLAND PREVENTIVE CARDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:MAYS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS, FACC
Authorized Official - Phone:503-292-5678
Mailing Address - Street 1:8855 SW CANYON LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-3411
Mailing Address - Country:US
Mailing Address - Phone:503-292-5678
Mailing Address - Fax:503-292-6665
Practice Address - Street 1:8855 SW CANYON LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-3411
Practice Address - Country:US
Practice Address - Phone:503-292-5678
Practice Address - Fax:503-292-6665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25708261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213623Medicaid
BM6442658OtherDEA
BM6442658OtherDEA