# INTERSTATE MEDICAL GROUP LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1932839776
- **Authorized official:** MICHAEL LOGIUDICE DC (OWNER)
- **Authorized official phone:** (503) 339-7351

## Contact information

- **Practice address:** 17221 SE DIVISION ST, PORTLAND, OR 97236-1240
- **Practice address phone:** (503) 760-0778
- **Practice address fax:** (503) 760-0753
- **Mailing address:** 17221 SE DIVISION ST, PORTLAND, OR 97236-1240
- **Mailing address phone:** (503) 760-0778
- **Mailing address fax:** (503) 760-0753

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 111N00000X | Chiropractor | — | NULL | — |
| 111N00000X | Chiropractor | — | — | — |
| 225700000X | Massage Therapist | — | NULL | — |
| 225700000X | Massage Therapist | — | — | — |
| 261QM1300X | Multi-Specialty Clinic/Center | — | NULL | — |
| 261QM2500X | Medical Specialty Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 06/14/2022
- **Last updated:** 08/24/2022