Provider Demographics
NPI:1417112616
Name:OREGON CLINIC PC
Entity Type:Organization
Organization Name:OREGON CLINIC PC
Other - Org Name:NSWA SALEM
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:S
Authorized Official - Last Name:FAUSEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-963-2801
Mailing Address - Street 1:PO BOX 5087
Mailing Address - Street 2:MS 163
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-5087
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:SUITE 5020
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3975
Practice Address - Country:US
Practice Address - Phone:503-963-2801
Practice Address - Fax:503-963-2825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR160412174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR115777Medicare PIN