| Gresham Internal Medicine Clinic | |
|
24900 Se Stark St Ste 109 Gresham OR 97030-3381 | |
| (503) 667-1015 | |
| (503) 667-0406 |
| Full Name | Gresham Internal Medicine Clinic |
|---|---|
| Speciality | Internal Medicine |
| Location | 24900 Se Stark St Ste 109, Gresham, Oregon |
| Authorized Official Name and Position | John M Custis (OWNER/PARTNER) |
| Authorized Official Contact | 5036671015 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Gresham Internal Medicine Clinic Po Box 23200 Portland OR 97281-3200 Ph: (503) 667-1015 | Gresham Internal Medicine Clinic 24900 Se Stark St Ste 109 Gresham OR 97030-3381 Ph: (503) 667-1015 |
| NPI Number | 1134204340 |
|---|---|
| Provider Enumeration Date | 10/26/2006 |
| Last Update Date | 12/11/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1134204340 | NPI | - | NPPES |
| CS0995 | Other | OR | RAILROAD MEDICARE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | 01794 (Oregon) | Primary |
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