Basic Information
| Provider Information | |||||||||
| NPI: | 1497760045 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OREGON WEIGHT LOSS SURGERY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 NE 20TH AVE STE 340 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032275050 | ||||||||
| FaxNumber: | 5032272462 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 NE 20TH AVE STE 340 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032275050 | ||||||||
| FaxNumber: | 5032272462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | PATTERSON | ||||||||
| AuthorizedOfficialFirstName: | EMMA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5032275050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 12694364 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | DF6325 | 01 | OR | RAILROAD MEDICARE | OTHER |