Basic Information
| Provider Information | |||||||||
| NPI: | 1417969304 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OREGON HEALTH & SCIENCE UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OHSU SCAPPOOSE RURAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 51377 SW OLD PORTLAND RD | ||||||||
| Address2: | |||||||||
| City: | SCAPPOOSE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970564023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034184222 | ||||||||
| FaxNumber: | 5034184223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 03/27/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH (JOE) | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, OHSU | ||||||||
| AuthorizedOfficialTelephone: | 5034948252 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 276320 | 05 | OR | MEDICAID | 7133135 | 05 | WA | MEDICAID |