NPIMap

Organization Active NPI

Mountain West Derm-Blackhart, PLLC

  • Dermatology Physician
  • Tigard, OR
National Provider Identifier
1316656994
Registry record updated Nov 22, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
MOUNTAIN WEST DERM-BLACKHART, PLLC
Practice address
10215 SW Hall Blvd
Tigard, OR 97223-8809
Phone
(503) 245-2415
Fax
(503) 244-5963
NPI assigned
Nov 22, 2022
Organization subpart
Yes
Parent organization
MOUNTAIN WEST DERM-BLACKHART, PLLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 22, 2022

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

Authorized official

Name
Jeffrey B ShackeltonNPI 1699902726
Title
Owner
Phone
(775) 283-4086

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

10215 SW Hall Blvd
Tigard, OR 97223-8809

Mailing address

10215 SW Hall Blvd
Tigard, OR 97223-8809
Phone (503) 245-2415

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20171219002516 OR Part B Supplier - Clinic/Group Practice 1153609813 Receives reassigned benefits from 39 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Tigard, OR; Roseburg, OR; Redmond, OR; Bend, OR; Prineville, OR; Klamath Falls, OR; Lake Oswego, OR; Ashland, OR

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Mountain W Derm- Blackhart

Locations

3640 Warren Way
Ste 100
Reno, NV 89509

10479 Double R Blvd
Reno, NV 89521
Phone (775) 850-8600

3640 Warren Way
Ste 200
Reno, NV 89509

111 NW Larch Ave
Redmond, OR 97756
Phone (541) 585-7546

Practitioners & affiliated clinicians

Practitioners 138

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 138

NPI Registry JSON

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

{
    "created_epoch": "1669075200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1669075200000",
    "number": "1316656994",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10215 SW HALL BLVD",
            "city": "TIGARD",
            "state": "OR",
            "postal_code": "972238809",
            "telephone_number": "503-245-2415",
            "fax_number": "503-244-5963"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10215 SW HALL BLVD",
            "city": "TIGARD",
            "state": "OR",
            "postal_code": "972238809",
            "telephone_number": "503-245-2415",
            "fax_number": "503-244-5963"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN WEST DERM-BLACKHART, PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MOUNTAIN WEST DERM-BLACKHART, PLLC",
        "enumeration_date": "2022-11-22",
        "last_updated": "2022-11-22",
        "certification_date": "2022-11-22",
        "status": "A",
        "authorized_official_last_name": "SHACKELTON",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "775-283-4086"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tigard, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 22, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.