Provider Demographics
NPI:1417287137
Name:EAST PORTLAND SURGERY CENTER LLC
Entity Type:Organization
Organization Name:EAST PORTLAND SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARKET PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-567-0269
Mailing Address - Street 1:14201 DALLAS PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2916
Mailing Address - Country:US
Mailing Address - Phone:469-893-2500
Mailing Address - Fax:504-322-3284
Practice Address - Street 1:9200 SE 91ST AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-3756
Practice Address - Country:US
Practice Address - Phone:503-772-6160
Practice Address - Fax:503-772-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-31
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07-1604261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500624087Medicaid
ORP00864506OtherRAILROAD MEDICARE
AZ38C0001074Medicare Oscar/Certification
OR500624087Medicaid