Provider Demographics
NPI:1598711996
Name:WILLAMETTE ANESTHESIOLOGY GROUP
Entity Type:Organization
Organization Name:WILLAMETTE ANESTHESIOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:HERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-655-0255
Mailing Address - Street 1:PO BOX 1600
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-0600
Mailing Address - Country:US
Mailing Address - Phone:503-655-0255
Mailing Address - Fax:503-655-0255
Practice Address - Street 1:1500 DIVISION ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1527
Practice Address - Country:US
Practice Address - Phone:503-656-1631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288046Medicaid
OR288046Medicaid