| Bridge City Family Medical Clinic, Pc | |
|
1410 Ne 106th Ave Portland OR 97220-3934 | |
| (503) 460-0405 | |
| (503) 460-0434 |
| Full Name | Bridge City Family Medical Clinic, Pc |
|---|---|
| Speciality | Clinic/Center |
| Location | 1410 Ne 106th Ave, Portland, Oregon |
| Authorized Official Name and Position | Theresa Bunker (OWNER) |
| Authorized Official Contact | 5034600405 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Bridge City Family Medical Clinic, Pc 1410 Ne 106th Ave Portland OR 97220-3934 Ph: (503) 460-0405 | Bridge City Family Medical Clinic, Pc 1410 Ne 106th Ave Portland OR 97220-3934 Ph: (503) 460-0405 |
| NPI Number | 1548330715 |
|---|---|
| Provider Enumeration Date | 11/08/2006 |
| Last Update Date | 09/30/2011 |
| Medicare PECOS PAC ID | 7810988292 |
|---|---|
| Medicare Enrollment ID | O20040524000631 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1548330715 | NPI | - | NPPES |
| 227632 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | 227362 (Oregon) | Primary |
| Provider Name | Theresa Lee Bunker |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1316017585 PECOS PAC ID: 2062403454 Enrollment ID: I20040525000092 |
| Provider Name | Ann Holly Cecil Cannon |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1124769823 PECOS PAC ID: 3678950466 Enrollment ID: I20220517001287 |
| Provider Name | Stefan Bulatovic |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1750053559 PECOS PAC ID: 3779965280 Enrollment ID: I20220801000557 |
| Provider Name | Ryan Arnold |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1407345614 PECOS PAC ID: 0648616797 Enrollment ID: I20240311003927 |
| Provider Name | Debra Anne Shannon |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598517088 PECOS PAC ID: 8426498866 Enrollment ID: I20240501003719 |
| Provider Name | Sarah E Quewakum |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1639450026 PECOS PAC ID: 7416310024 Enrollment ID: I20240812000822 |
| Provider Name | Elizabeth D Jaramillo |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1477101509 PECOS PAC ID: 5890234611 Enrollment ID: I20240826000360 |
| Provider Name | Kacy L Herbst |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1053106039 PECOS PAC ID: 0648796664 Enrollment ID: I20250501003236 |
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