Provider Demographics
NPI:1548467129
Name:NORTHWEST PEDIATRIC GASTROENTEROLOGY, LLC
Entity type:Organization
Organization Name:NORTHWEST PEDIATRIC GASTROENTEROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:P
Authorized Official - Last Name:SCHULZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-281-5139
Mailing Address - Street 1:300 N GRAHAM ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1683
Mailing Address - Country:US
Mailing Address - Phone:503-281-5139
Mailing Address - Fax:503-249-3782
Practice Address - Street 1:300 N GRAHAM ST
Practice Address - Street 2:SUITE 420
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1683
Practice Address - Country:US
Practice Address - Phone:503-281-5139
Practice Address - Fax:503-249-3782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OROREGONMedicaid
WAWASHINGTONMedicaid