Basic Information
| Provider Information | |||||||||
| NPI: | 1902062672 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA LUTHERAN CHARITIES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CMH UROLOGY CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2111 EXCHANGE ST | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033254321 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2120 EXCHANGE ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033257888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2008 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | THORSEN | ||||||||
| AuthorizedOfficialFirstName: | ERIK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5033254321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 141146 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.