Basic Information
| Provider Information | |||||||||
| NPI: | 1497046205 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OREGON CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5277 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972085277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632801 | ||||||||
| FaxNumber: | 5039632825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 NE 99TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039633030 | ||||||||
| FaxNumber: | 5039633140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2011 | ||||||||
| LastUpdateDate: | 12/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | FAUSEL | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | STEPHEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5039632801 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 160412 | OR | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.