NPIMap

Organization Active NPI

Interstate Medical Group LLC

  • Medical Specialty Clinic/Center
  • Portland, OR
National Provider Identifier
1932839776
Registry record updated Aug 24, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Specialty Clinic/CenterTaxonomy code 261QM2500X
Legal business name
INTERSTATE MEDICAL GROUP LLC
Practice address
17221 SE Division St
Portland, OR 97236-1240
Phone
(503) 760-0778
Fax
(503) 760-0753
NPI assigned
Jun 14, 2022
Last updated
Aug 24, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 24, 2022

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

Authorized official

Name
Michael Logiudice, DCNPI 1972785921
Title
Owner
Phone
(503) 339-7351

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 4

Specialty (taxonomy)CodeLicenseStatePrimary
Chiropractor 111N00000X
Massage Therapist 225700000X
Multi-Specialty Clinic/Center 261QM1300X
Medical Specialty Clinic/Center 261QM2500X Primary

Addresses

Primary practice location

17221 SE Division St
Portland, OR 97236-1240

Mailing address

17221 SE Division St
Portland, OR 97236-1240
Phone (503) 760-0778

National Provider Directory

National Provider Directory

Locations

17221 SE Division St
Portland, OR 97236
Phone (503) 760-0778

1410 Lancaster Dr NE
Salem, OR 97301
Phone (503) 339-7351

Practitioners & affiliated clinicians

Practitioners 9

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": "1655164800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1661299200000",
    "number": "1932839776",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17221 SE DIVISION ST",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972361240",
            "telephone_number": "503-760-0778",
            "fax_number": "503-760-0753"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17221 SE DIVISION ST",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972361240",
            "telephone_number": "503-760-0778",
            "fax_number": "503-760-0753"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTERSTATE MEDICAL GROUP LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-06-14",
        "last_updated": "2022-08-24",
        "certification_date": "2022-08-24",
        "status": "A",
        "authorized_official_last_name": "LOGIUDICE",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "503-339-7351",
        "authorized_official_credential": "DC"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "",
            "desc": "Chiropractor",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "225700000X",
            "taxonomy_group": "",
            "desc": "Massage Therapist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "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 Aug 24, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.