Provider Demographics
NPI:1447223466
Name:NORTHWESTERN NEUROLOGICAL ASSOC PC
Entity Type:Organization
Organization Name:NORTHWESTERN NEUROLOGICAL ASSOC PC
Other - Org Name:NORTHWESTERN NEUROLOGICAL ASSOCIATES PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GREWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-288-5151
Mailing Address - Street 1:501 N GRAHAM ST
Mailing Address - Street 2:SUITE 545
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1654
Mailing Address - Country:US
Mailing Address - Phone:503-288-5151
Mailing Address - Fax:503-288-4942
Practice Address - Street 1:501 N GRAHAM ST
Practice Address - Street 2:SUITE 545
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1654
Practice Address - Country:US
Practice Address - Phone:503-288-5151
Practice Address - Fax:503-288-4942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR004197Medicaid
ORR0000WCJVQOtherPTAN
001782000OtherBCBS