Provider Demographics
NPI:1124603055
Name:NORTHWEST EXTREMITY SPECIALISTS LLC
Entity Type:Organization
Organization Name:NORTHWEST EXTREMITY SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:MELILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-245-2420
Mailing Address - Street 1:9115 SW OLESON RD STE 205
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6877
Mailing Address - Country:US
Mailing Address - Phone:503-245-2420
Mailing Address - Fax:
Practice Address - Street 1:12658 SE STARK ST BLDG H
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-221-1581
Practice Address - Fax:503-221-1582
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST EXTREMITY SPECIALISTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric