Basic Information
Provider Information | |||||||||
NPI: | 1427139732 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OREGON SURGICAL SPECIALISTS PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 520 MEDICAL CENTER DR | ||||||||
Address2: | STE 300 | ||||||||
City: | MEDFORD | ||||||||
State: | OR | ||||||||
PostalCode: | 975044316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5419308907 | ||||||||
FaxNumber: | 5412826710 | ||||||||
Practice Location | |||||||||
Address1: | 520 MEDICAL CENTER DR | ||||||||
Address2: | STE 300 | ||||||||
City: | MEDFORD | ||||||||
State: | OR | ||||||||
PostalCode: | 975044316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5419308907 | ||||||||
FaxNumber: | 5412826710 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2006 | ||||||||
LastUpdateDate: | 07/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STREET | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT OF CORPORATION | ||||||||
AuthorizedOfficialTelephone: | 5419308907 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0129X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 004898000 | 01 | OR | BLUE CROSS | OTHER | 081653 | 05 | OR |   | MEDICAID |