Provider Demographics
NPI:1073778346
Name:THE OREGON CLINIC PC
Entity Type:Organization
Organization Name:THE OREGON CLINIC PC
Other - Org Name:THE OREGON CLINIC ENDOSCOPY CENTER - EAST
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:S
Authorized Official - Last Name:FAUSEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-963-2801
Mailing Address - Street 1:PO BOX 5087
Mailing Address - Street 2:MS 163
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-5087
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1111 NE 99TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9428
Practice Address - Country:US
Practice Address - Phone:503-963-2801
Practice Address - Fax:503-963-2825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07-1535261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000366Medicaid
OR000366Medicaid