Provider Demographics
NPI:1205207073
Name:NORTHWEST EXTREMITY SPECIALISTS
Entity Type:Organization
Organization Name:NORTHWEST EXTREMITY SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCCAMMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-667-6600
Mailing Address - Street 1:6542 SE LAKE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2245
Mailing Address - Country:US
Mailing Address - Phone:503-667-6600
Mailing Address - Fax:503-667-6608
Practice Address - Street 1:831 NW COUNCIL DR STE 203
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3723
Practice Address - Country:US
Practice Address - Phone:503-667-6600
Practice Address - Fax:503-667-6608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR332BC3200X332B00000X
OR335E00000X335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR179836Medicare UPIN