Provider Demographics
NPI:1447481866
Name:NORTHWEST LIFESTYLE MEDICINE, INC.
Entity type:Organization
Organization Name:NORTHWEST LIFESTYLE MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:971-983-5433
Mailing Address - Street 1:PO BOX 4141
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-8141
Mailing Address - Country:US
Mailing Address - Phone:971-983-5433
Mailing Address - Fax:971-983-5434
Practice Address - Street 1:6250 COMMERCIAL ST SE
Practice Address - Street 2:SUITE 100
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-1333
Practice Address - Country:US
Practice Address - Phone:971-983-5433
Practice Address - Fax:971-983-5434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD216302083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500656754Medicaid