Provider Demographics
NPI:1598798365
Name:ADVANTAGE ORTHOPEDIC AND SPORTS MEDICINE CLINIC LLP
Entity Type:Organization
Organization Name:ADVANTAGE ORTHOPEDIC AND SPORTS MEDICINE CLINIC LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOXSIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-661-5388
Mailing Address - Street 1:24076 SE STARK
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3374
Mailing Address - Country:US
Mailing Address - Phone:503-661-5388
Mailing Address - Fax:503-666-9393
Practice Address - Street 1:24076 SE STARK
Practice Address - Street 2:SUITE 110
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3374
Practice Address - Country:US
Practice Address - Phone:503-661-5388
Practice Address - Fax:503-666-9393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101160Medicare PIN
OR101160Medicare UPIN
OR3945170001Medicare NSC