Provider Demographics
NPI:1477513737
Name:OREGON CLINIC, PC
Entity Type:Organization
Organization Name:OREGON CLINIC, PC
Other - Org Name:THE OREGON CLINIC ENDOSCOPY CENTER - OREGON CITY
Other - Org Type:Doing Business As
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 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1508 DIVISION ST
Practice Address - Street 2:SUITE 15
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045
Practice Address - Country:US
Practice Address - Phone:503-692-3750
Practice Address - Fax:503-691-2324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR394719261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500626764Medicaid
OR131495Medicaid
OR500626764Medicaid
OR170951Medicare PIN