Provider Demographics
NPI:1497046205
Name:OREGON CLINIC PC
Entity Type:Organization
Organization Name:OREGON CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:FAUSEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-963-2801
Mailing Address - Street 1:PO BOX 5277
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-5277
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1111 NE 99TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-963-3030
Practice Address - Fax:503-963-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-27
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR160412332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies