Provider Demographics
NPI:1609914605
Name:PORTLAND SURGICAL SPECIALISTS, PC
Entity Type:Organization
Organization Name:PORTLAND SURGICAL SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:EUBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-353-3005
Mailing Address - Street 1:9200 SE 91ST AVE
Mailing Address - Street 2:#320
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97086
Mailing Address - Country:US
Mailing Address - Phone:503-353-3005
Mailing Address - Fax:503-546-3201
Practice Address - Street 1:9200 SE 91ST AVE
Practice Address - Street 2:#320
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97086
Practice Address - Country:US
Practice Address - Phone:503-353-3005
Practice Address - Fax:503-546-3201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278453Medicaid
OR858363000OtherREGENCE BCBS
OR858363000OtherREGENCE BCBS