Provider Demographics
NPI:1265473623
Name:PACIFIC SURGICAL SPECIALISTS LLC
Entity Type:Organization
Organization Name:PACIFIC SURGICAL SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:DALLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-213-9955
Mailing Address - Street 1:PO BOX 23200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97281-3200
Mailing Address - Country:US
Mailing Address - Phone:360-213-9955
Mailing Address - Fax:
Practice Address - Street 1:505 NE 87TH AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1989
Practice Address - Country:US
Practice Address - Phone:360-213-9955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278191Medicaid
WA7128093Medicaid
WA7128093Medicaid
ORR131291Medicare PIN