Provider Demographics
NPI:1437338530
Name:SANTIAM ORTHOPEDICS AND SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:SANTIAM ORTHOPEDICS AND SPORTS MEDICINE PC
Other - Org Name:RAYLENE GORDIN M.D., P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYLENE
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:GORDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-375-3636
Mailing Address - Street 1:700 BELLEVUE ST SE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3819
Mailing Address - Country:US
Mailing Address - Phone:503-375-3636
Mailing Address - Fax:503-375-3737
Practice Address - Street 1:700 BELLEVUE ST SE
Practice Address - Street 2:SUITE 260
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3819
Practice Address - Country:US
Practice Address - Phone:503-375-3636
Practice Address - Fax:503-375-3737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19742207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR081356Medicaid
OR081356Medicaid
OR110344Medicare PIN