Provider Demographics
NPI:1376709535
Name:UNIVERSITY PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:UNIVERSITY PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. ASSOC. DEAN, CLINICAL PRACTICE
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MASCIOTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-494-5099
Mailing Address - Street 1:1400 SW 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:503-494-8417
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-8311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276228Medicaid
OR276228Medicaid