| NPI | 1790107050 |
|---|---|
| Doing Business As | PROVIDENCE MEDICAL GROUP GLISAN DERMATOLOGY AT SUNNYSIDE |
| Entity Type | Organization |
| Authorized Contact | KEENAN B FREEMAN CFO 503-893-6524 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center |
| Enumeration Date | 2014-01-06 |
| Last Update Date | 2014-12-30 |