Provider Demographics
NPI:1447874367
Name:PDX ALLERGY LLC
Entity type:Organization
Organization Name:PDX ALLERGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MERRIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-358-5600
Mailing Address - Street 1:9200 SE 91ST AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-3756
Mailing Address - Country:US
Mailing Address - Phone:971-358-5600
Mailing Address - Fax:971-358-5601
Practice Address - Street 1:8740 SE SUNNYBROOK BLVD STE 300
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5737
Practice Address - Country:US
Practice Address - Phone:971-358-5600
Practice Address - Fax:971-358-5601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-05
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1447874367Medicaid
OR500784605Medicaid