Provider Demographics
NPI:1467449462
Name:THE UROLOGY CLINIC PC
Entity Type:Organization
Organization Name:THE UROLOGY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-288-7303
Mailing Address - Street 1:501 N GRAHAM ST
Mailing Address - Street 2:STE 420
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1654
Mailing Address - Country:US
Mailing Address - Phone:503-288-7303
Mailing Address - Fax:503-280-1993
Practice Address - Street 1:501 N GRAHAM ST
Practice Address - Street 2:STE 420
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1654
Practice Address - Country:US
Practice Address - Phone:503-288-7303
Practice Address - Fax:503-280-1993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR109371Medicaid
ORCP7690OtherMEDICARE RAILROAD
WA7858004Medicaid
WA7858004Medicaid
0000WCGCNMedicare ID - Type Unspecified