Provider Demographics
NPI:1093713729
Name:OREGON SPORTS MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:OREGON SPORTS MEDICINE ASSOCIATES
Other - Org Name:SPORTS MEDICINE OREGON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:GREENLEAF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-692-8700
Mailing Address - Street 1:7300 SW CHILDS RD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7713
Mailing Address - Country:US
Mailing Address - Phone:503-692-8700
Mailing Address - Fax:503-692-8710
Practice Address - Street 1:7300 SW CHILDS RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7713
Practice Address - Country:US
Practice Address - Phone:503-692-8700
Practice Address - Fax:503-692-8710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OOOOWCYBCMedicare ID - Type Unspecified