1164464616 NPI number — GASTROENTEROLOGY SPECIALISTS OF OREGON PC

Table of content: (NPI 1164464616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164464616 NPI number — GASTROENTEROLOGY SPECIALISTS OF OREGON PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTROENTEROLOGY SPECIALISTS OF OREGON PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLACKAMAS GASTROENTEROLOGY
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164464616
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1508 DIVISION ST
Provider Second Line Business Mailing Address:
SUITE 15
Provider Business Mailing Address City Name:
OREGON CITY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97045-1583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-657-5555
Provider Business Mailing Address Fax Number:
503-657-6502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1508 DIVISION ST
Provider Second Line Business Practice Location Address:
SUITE 15
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-1583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-657-5555
Provider Business Practice Location Address Fax Number:
503-657-6502
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAUSCHER
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
971-224-2457

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 171447 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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