GEROMEDICAL PSYCHOLOGICAL SERVICES, PS - NPI NUMBER 1043501836

Summary

Provider Name: GEROMEDICAL PSYCHOLOGICAL SERVICES, PS

NPI Number: 1043501836

Clasification: Psychologist (103TC0700X)

Specialization: Clinical

Address:
3550 SW BOND AVE
PORTLAND, OR
ZIP 97239

Phone Number: (360) 574-9565



Detailed Information

GEROMEDICAL PSYCHOLOGICAL SERVICES, PS is a clinical psychologist in Portland, OR. The assigned NPI number for this provider is 1043501836 and is registered as an organization entity type and is a single specialty group.

The provider's business address is:

3550 SW BOND AVE
PORTLAND, OR
ZIP 97239-507
Phone: (360) 574-9565
Fax: (360) 574-9685

The provider's authorized official is Derick A Scovel .
The authorized official title is President and has the following contact phone number (360) 574-9565.

The enumeration date for this NPI number is 4/27/2011 and was last updated on 1/29/2014.

Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 103TC0700X Psychologist Clinical 2074 OR Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 R159409 MEDICARE UPIN OR

NPI Record

No. Field Name Field Value
1 NPI 1043501836
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name GEROMEDICAL PSYCHOLOGICAL SERVICES, PS
5 Provider First Line Business Practice Location Address 3550 SW BOND AVE
6 Provider Business Practice Location Address City Name PORTLAND
7 Provider Business Practice Location Address State Name OR
8 Provider Business Practice Location Address Postal Code 972394507
9 Provider Business Practice Location Address Country Code If outside U S US
10 Provider Business Practice Location Address Telephone Number 3605749565
11 Provider Business Practice Location Address Fax Number 3605749685
12 Provider Enumeration Date 4/27/2011
13 Last Update Date 1/29/2014
14 Authorized Official Last Name SCOVEL
15 Authorized Official First Name DERICK
16 Authorized Official Middle Name A
17 Authorized Official Title or Position PRESIDENT
18 Authorized Official Telephone Number 3605749565
19 Healthcare Provider Taxonomy Code 1 103TC0700X
20 Provider License Number 1 2074
21 Provider License Number State Code 1 OR
22 Healthcare Provider Primary Taxonomy Switch 1 Y
23 Other Provider Identifier 1 R159409
24 Other Provider Identifier Type Code 1 02
25 Other Provider Identifier State 1 OR
26 Is Organization Subpart N
27 Authorized Official Name Prefix Text DR.
28 Authorized Official Credential Text PHD
29 Healthcare Provider Taxonomy Group 1 193400000X SINGLE SPECIALTY GROUP

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This page was last updated on: 7/15/2014
All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.