NPIMap

Organization Active NPI

Fanno Creek Clinic LLC

  • Internal Medicine Physician
  • Portland, OR
National Provider Identifier
1609876705
Registry record updated Oct 16, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
2802 Issued in OR
Legal business name
FANNO CREEK CLINIC LLC
Practice address
2400 SW Vermont St
Portland, OR 97219-1940
Phone
(503) 452-0915
Fax
(503) 768-9232
NPI assigned
Jul 29, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 16, 2007

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

Authorized official

Name
Larry M Reed
Title
Clinic Manager
Phone
(503) 452-0915

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207R00000X 2802 OR Primary

Addresses

Primary practice location

2400 SW Vermont St
Portland, OR 97219-1940

Mailing address

2400 SW Vermont St
Portland, OR 97219-1940
Phone (503) 452-0915

Other identifiers 1

IdentifierTypeStateIssuer
151070MedicaidOR

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040318000244 OR Part B Supplier - Clinic/Group Practice 0042100521 Receives reassigned benefits from 54 practitioners
Practice locations: Portland, OR

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
38D0927861Fanno Creek Clinic LLC2400 SW Vermont St, Portland, OR 97219ComplianceOct 17, 2027

National Provider Directory

National Provider Directory

Locations

2400 SW Vermont St
Portland, OR 97219
Phone (503) 452-0915

Interoperability endpoints

  • Direct secure messaging: mlevitte@direct.fannocreek.com
  • Direct secure messaging: ckuttner@direct.fannocreek.com

Practitioners & affiliated clinicians

Practitioners 54

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

View all 54

NPI Registry JSON

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

{
    "created_epoch": "1122595200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1192492800000",
    "number": "1609876705",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2400 SW VERMONT ST",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972191940",
            "telephone_number": "503-452-0915",
            "fax_number": "503-768-9232"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2400 SW VERMONT ST",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972191940",
            "telephone_number": "503-452-0915",
            "fax_number": "503-768-9232"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FANNO CREEK CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-29",
        "last_updated": "2007-10-16",
        "status": "A",
        "authorized_official_last_name": "REED",
        "authorized_official_first_name": "LARRY",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CLINIC MANAGER",
        "authorized_official_telephone_number": "503-452-0915"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": "OR",
            "license": "2802",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "151070",
            "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 Oct 16, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • 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.