Provider Demographics
NPI:1235195447
Name:GRESHAM STATION SURGERY CENTER LLC
Entity Type:Organization
Organization Name:GRESHAM STATION SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:503-907-1907
Mailing Address - Street 1:831 NW COUNCIL DRIVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-907-1907
Mailing Address - Fax:503-489-2073
Practice Address - Street 1:831 NW COUNCIL DRIVE
Practice Address - Street 2:SUITE 212
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-907-1907
Practice Address - Fax:503-489-2073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR394819261QA1903X
OR07-1567261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213664Medicaid
132134Medicare PIN
R132134Medicare UPIN