Provider Demographics
NPI:1679605315
Name:ALBERTY, ROGER ELLIS (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:ELLIS
Last Name:ALBERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205
Mailing Address - Country:US
Mailing Address - Phone:503-221-0161
Mailing Address - Fax:503-221-4451
Practice Address - Street 1:800 SW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205
Practice Address - Country:US
Practice Address - Phone:503-221-0161
Practice Address - Fax:503-221-4451
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08496208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR262345Medicaid
02WCHQRAMedicare ID - Type Unspecified
OR262345Medicaid