Provider Demographics
NPI:1174858955
Name:WEST PORTLAND SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:WEST PORTLAND SURGERY CENTER, LLC
Other - Org Name:CORNELL SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CLNC
Authorized Official - Phone:503-533-4800
Mailing Address - Street 1:16985 NW CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-5639
Mailing Address - Country:US
Mailing Address - Phone:503-533-4800
Mailing Address - Fax:503-533-4884
Practice Address - Street 1:16985 NW CORNELL RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5639
Practice Address - Country:US
Practice Address - Phone:503-533-4800
Practice Address - Fax:503-533-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-12
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
OR25323261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR150571Medicare PIN