Provider Demographics
NPI:1932232741
Name:NORTHWEST INTERNAL MEDICINE LLC
Entity type:Organization
Organization Name:NORTHWEST INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TANA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-329-1851
Mailing Address - Street 1:PO BOX 869
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-0869
Mailing Address - Country:US
Mailing Address - Phone:503-329-1851
Mailing Address - Fax:503-885-8946
Practice Address - Street 1:19260 SW 65TH AVE STE 270
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-5705
Practice Address - Country:US
Practice Address - Phone:503-329-1851
Practice Address - Fax:503-885-8946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24660174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029123Medicaid
OR029123Medicaid