Provider Demographics
NPI:1548412224
Name:BEND DERMATOLOGY CLINIC LLC
Entity Type:Organization
Organization Name:BEND DERMATOLOGY CLINIC LLC
Other - Org Name:CASCADIA HISTOPATHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAITLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-322-1980
Mailing Address - Street 1:2747 NE CONNERS AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-8738
Mailing Address - Country:US
Mailing Address - Phone:541-382-5712
Mailing Address - Fax:541-382-2605
Practice Address - Street 1:2705 NE CONNERS AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6904
Practice Address - Country:US
Practice Address - Phone:541-382-5712
Practice Address - Fax:541-382-2605
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEND DERMATOLOGY CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-14
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR38D0628271291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00692242OtherRAIL ROAD MEDICARE PTAN
ORR143867Medicare PIN