Provider Demographics
NPI:1871050153
Name:ORTHOPEDIC & FRACTURE CLINIC PC
Entity type:Organization
Organization Name:ORTHOPEDIC & FRACTURE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J BRAD
Authorized Official - Middle Name:V
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:V
Authorized Official - Credentials:MD
Authorized Official - Phone:503-214-5200
Mailing Address - Street 1:11782 SW BARNES RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5931
Mailing Address - Country:US
Mailing Address - Phone:503-906-4302
Mailing Address - Fax:503-840-3004
Practice Address - Street 1:11782 SW BARNES RD STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5933
Practice Address - Country:US
Practice Address - Phone:503-214-5200
Practice Address - Fax:503-906-6613
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHOPEDIC & FRACTURE CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR146456Medicaid