1952567653 NPI number — OREGON UROLOGY CLINIC, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952567653 NPI number — OREGON UROLOGY CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OREGON UROLOGY CLINIC, P.C.
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:
Provider Other Organization Name Type Code:
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:
1952567653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2222 NW LOVEJOY STREET SUITE 416
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97210-5102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-229-7722
Provider Business Mailing Address Fax Number:
503-222-5679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 NE 28TH STREET SUITE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97367-4518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-229-7722
Provider Business Practice Location Address Fax Number:
503-222-5679
Provider Enumeration Date:
08/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROSENCRANTZ
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PHYSICIAN/SURGEON
Authorized Official Telephone Number:
503-229-7722

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  MD07089 , 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: 287875 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38D1047175 . This is a "CLIA ID#" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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