Provider Demographics
NPI:1215221205
Name:WILLAMETTE UROLOGY PC
Entity Type:Organization
Organization Name:WILLAMETTE UROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-561-7112
Mailing Address - Street 1:875 OAK ST SE
Mailing Address - Street 2:SUITE 5030
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3975
Mailing Address - Country:US
Mailing Address - Phone:503-561-7100
Mailing Address - Fax:503-561-7124
Practice Address - Street 1:591 SE CLAY ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-2812
Practice Address - Country:US
Practice Address - Phone:503-561-7100
Practice Address - Fax:503-561-7124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR01954353174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty