1831167253 NPI number — OREGON CLINIC, PC

Table of content: (NPI 1831167253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831167253 NPI number — OREGON CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OREGON CLINIC, 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:
THE OREGON CLINIC ENDOSCOPY CENTER - TUALATIN
Provider Other Organization Name Type Code:
3
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:
1831167253
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
847 NE 19TH AVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97232-2684
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-963-2801
Provider Business Mailing Address Fax Number:
503-963-2825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19250 SW 90TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUALATIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97062-7585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-692-3750
Provider Business Practice Location Address Fax Number:
503-691-2324
Provider Enumeration Date:
03/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FAUSEL
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
503-963-2801

Provider Taxonomy Codes

  • Taxonomy code: 261QE0800X , with the licence number:  394719 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 131495 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".