Provider Demographics
NPI: | 1134145360 |
---|---|
Name: | WILLAMETTE ORTHOPEDIC GROUP LLC |
Entity Type: | Organization |
Organization Name: | WILLAMETTE ORTHOPEDIC GROUP LLC |
Other - Org Name: | HOPE ORTHOPEDICS OF OREGON |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | LORISSA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ADDABBO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 503-540-6465 |
Mailing Address - Street 1: | 1600 STATE ST |
Mailing Address - Street 2: | |
Mailing Address - City: | SALEM |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97301-4257 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-540-6300 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1600 STATE ST |
Practice Address - Street 2: | |
Practice Address - City: | SALEM |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97301-4257 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-540-6300 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-07-14 |
Last Update Date: | 2021-02-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
207X00000X, 207XS0106X, 207XS0114X, 207XX0004X, 207XX0005X, 207XX0801X, 225100000X, 225XH1200X, 332B00000X, 363A00000X, 363AS0400X | ||
OR | OTC090820 | 225000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207XS0106X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | Group - Multi-Specialty |
No | 207XS0114X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | Group - Multi-Specialty |
No | 207XX0004X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | Group - Multi-Specialty |
No | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | Group - Multi-Specialty |
No | 207XX0801X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | Group - Multi-Specialty |
No | 225000000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotic Fitter | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 225XH1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | Group - Multi-Specialty |
No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 278220 | Medicaid | |
OR | 278220 | Medicaid | |
OR | 133306 | Medicare PIN |