NPIMap

Individual provider Active NPI

Kathy Kiryang Bak, M.D.

  • Family Medicine Physician
  • Portland, OR
National Provider Identifier
1861412884
Registry record updated Oct 27, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
MD164294 Issued in OR
Practice address
12400 NW Cornell Rd Ste 100
Portland, OR 97229-5689
Phone
(503) 291-4000
NPI assigned
Jul 20, 2006
Last updated
Oct 27, 2023By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 27, 2023

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X A91888 CA
Family Medicine Physician 207Q00000X MD164294 OR Primary

Addresses

Primary practice location

12400 NW Cornell Rd Ste 100
Portland, OR 97229-5689

Mailing address

PO Box 3158
Portland, OR 97208-3158
Phone (503) 215-6494

Other identifiers 1

IdentifierTypeStateIssuer
500674133MedicaidOR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20131114000034 OR Practitioner - Family Practice 9335177476 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2002
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

12400 NW Cornell Rd
Suite 100
Portland, OR 97229-5689
Phone (503) 626-0939

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
MD164294ORMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Providence Health & Services Oregon Current Accepting new patients
Providence Health & Services - Oregon CurrentSince Sep 15, 2023 Accepting new patients
Kaiser Foundation Health Plan of the Northwest Family Medicine CurrentSince Jun 27, 2016 Accepting new patients
Providence Health & Services Oregon CurrentSince Sep 25, 2023 Accepting new patients
Providence Health & Services - Oregon CurrentSince Sep 25, 2023 Accepting new patients
Providence Health & Services - Oregon Family Medicine CurrentSince Sep 15, 2023 Accepting new patients
Kaiser Foundation Health Plan of the Northwest CurrentSince Jun 27, 2016 Accepting new patients
Providence Health & Services - Oregon Family Medicine Past Accepting new patients
Providence Facey Medical Foundation Family Medicine Past Accepting new patients

Locations

200 S Hazel Dell Way
Canby, OR 97013
Phone (203) 263-9500

10100 SE Sunnyside Rd
Clackamas, OR 97015
Phone (503) 571-2946

12400 NW Cornell Rd
Ste 100
Portland, OR 97229
Phone (503) 291-4000

5050 NE Hoyt St
Ste 240
Portland, OR 97213
Phone (503) 215-6480

9205 SW Barnes Rd
Portland, OR 97225
Phone (503) 216-1234

2400 Lancaster Dr NE
Salem, OR 97305
Phone (503) 361-5400

Interoperability endpoints

  • Direct secure messaging: kbak3002171@oc.providencedirect.org

Organizations & group practices 9

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1153353600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1698364800000",
    "number": "1861412884",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3158",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083158",
            "telephone_number": "503-215-6494"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12400 NW CORNELL RD STE 100",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972295689",
            "telephone_number": "503-291-4000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BAK",
        "first_name": "KATHY",
        "middle_name": "KIRYANG",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-07-20",
        "last_updated": "2023-10-27",
        "certification_date": "2023-10-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "CA",
            "license": "A91888",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OR",
            "license": "MD164294",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500674133",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Portland, OR

Sources for this page

Verify at the official NPI Registry.