Basic Information
| Provider Information | |||||||||
| NPI: | 1770516544 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST SURGICAL SPECIALISTS LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3355 RIVERBEND DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974778800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418689303 | ||||||||
| FaxNumber: | 5418689306 | ||||||||
| Practice Location | |||||||||
| Address1: | 3355 RIVERBEND DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418689303 | ||||||||
| FaxNumber: | 5418689306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | MULLEN | ||||||||
| AuthorizedOfficialFirstName: | GINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5418689377 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 240117 | 05 | OR | MEDICAID |