Basic Information
| Provider Information | |||||||||
| NPI: | 1760760599 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY PROFESSIONAL SERVICES | ||||||||
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| OtherOrganizationName: | OHSU CEI MOLECULAR DIAGNOSTIC LABORATORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | MAIL CODE: CEI | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948744 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3375 SW TERWILLIGER BLVD | ||||||||
| Address2: | MAIL CODE CEI | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034943000 | ||||||||
| FaxNumber: | 5034940470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2011 | ||||||||
| LastUpdateDate: | 07/27/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, UNIVERSITY | ||||||||
| AuthorizedOfficialTelephone: | 5034948133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OREGON HEALTH & SCIENCE UNIVERSITY | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 38D0623102 | 01 | OR | CLIA | OTHER |