Basic Information
| Provider Information | |||||||||
| NPI: | 1356609374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLOGNESE | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | CERUTTI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 S HAMILTON ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537034314 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034947810 | ||||||||
| FaxNumber: | 5034945292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2012 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204F00000X | 73045 | WI | N | Allopathic & Osteopathic Physicians | Transplant Surgery | 208600000X | MD210833 | OR | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 73045 | WI | N | Allopathic & Osteopathic Physicians | Surgery | 204F00000X | MD210833 | OR | Y | Allopathic & Osteopathic Physicians | Transplant Surgery |
ID Information
| ID | Type | State | Issuer | Description | MD210833 | 01 | OR | LICENSE | OTHER |