| Providence Lung Cancer Clinic | |
|
4805 Ne Glisan St Suite 6n50 Portland OR 97213-2933 | |
| (503) 215-3595 | |
| (503) 215-3599 |
| Full Name | Providence Lung Cancer Clinic |
|---|---|
| Speciality | Clinic/center |
| Location | 4805 Ne Glisan St, Portland, Oregon |
| Authorized Official Name and Position | Keenan B Freeman (CFO) |
| Authorized Official Contact | 5038936524 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Lung Cancer Clinic Po Box 3158 Portland OR 97208-3158 Ph: (503) 215-6494 | Providence Lung Cancer Clinic 4805 Ne Glisan St Suite 6n50 Portland OR 97213-2933 Ph: (503) 215-3595 |
| NPI Number | 1720315385 |
|---|---|
| Provider Enumeration Date | 11/03/2009 |
| Last Update Date | 09/25/2013 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1720315385 | NPI | - | NPPES |
| 7148794 | Medicaid | WA | |
| 500613933 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
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