NPIMap

Organization Active NPI

Westside Pediatric Clinic PC

  • Pediatrics Physician
  • Portland, OR
National Provider Identifier
1093929226
Registry record updated Apr 11, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
WESTSIDE PEDIATRIC CLINIC PC
Practice address
9555 SW Barnes Rd
Suite 270
Portland, OR 97225
Phone
(503) 297-1025
Fax
(503) 297-1043
NPI assigned
May 9, 2007
Last updated
Apr 11, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 11, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Connie Lynn Distefano
Title
Administrator
Phone
(503) 297-1025

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X Primary

Addresses

Primary practice location

9555 SW Barnes Rd
Suite 270
Portland, OR 97225

Mailing address

9555 SW Barnes Rd
Suite 270
Portland, OR 97225
Phone (503) 297-1025

Other identifiers 1

IdentifierTypeStateIssuer
150220MedicaidOR

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
38D0624959Westside Pediatric Clinic, PC9555 SW Barnes Rd #270, Portland, OR 97225Certificate of waiverSep 11, 2026

National Provider Directory

National Provider Directory

Locations

9555 SW Barnes Rd
Ste 270
Portland, OR 97225
Phone (503) 297-1025

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178668800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1207872000000",
    "number": "1093929226",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9555 SW BARNES RD",
            "address_2": "SUITE 270",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "97225",
            "telephone_number": "503-297-1025",
            "fax_number": "503-297-1043"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9555 SW BARNES RD",
            "address_2": "SUITE 270",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "97225",
            "telephone_number": "503-297-1025",
            "fax_number": "503-297-1043"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WESTSIDE PEDIATRIC CLINIC PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-09",
        "last_updated": "2008-04-11",
        "status": "A",
        "authorized_official_last_name": "DISTEFANO",
        "authorized_official_first_name": "CONNIE",
        "authorized_official_middle_name": "LYNN",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "503-297-1025",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "150220",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Portland, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 11, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.