Provider Demographics
NPI:1497998140
Name:SAMUEL G SHILEY MD LLC
Entity Type:Organization
Organization Name:SAMUEL G SHILEY MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-229-8455
Mailing Address - Street 1:2222 NW LOVEJOY ST
Mailing Address - Street 2:SUITE #622
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3033
Mailing Address - Country:US
Mailing Address - Phone:503-229-8455
Mailing Address - Fax:
Practice Address - Street 1:2222 NW LOVEJOY ST
Practice Address - Street 2:SUITE #622
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3033
Practice Address - Country:US
Practice Address - Phone:503-229-8455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25260207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORI19732Medicare UPIN