Organization
GRESHAM INTERNAL MEDICINE CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHN M CUSTIS MD (OWNER/PARTNER)
(503) 667-1015
Entity
Organization
Contact information
Practice address
24900 SE STARK ST STE 109, GRESHAM, OR 97030-3381
(503) 667-1015
(503) 667-0406
Mailing address
PO BOX 23200, PORTLAND, OR 97281-3200
(503) 667-1015
(503) 667-0406
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
01794
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CS0995
RAILROAD MEDICARE
OR
Enumeration date
10/26/2006
Last updated
12/11/2008
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