Provider Demographics
NPI:1619995172
Name:NORTHWEST UROLOGICAL CLINIC PC
Entity Type:Organization
Organization Name:NORTHWEST UROLOGICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:LASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-223-6223
Mailing Address - Street 1:2230 NW PETTYGROVE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2659
Mailing Address - Country:US
Mailing Address - Phone:503-223-6223
Mailing Address - Fax:503-223-3665
Practice Address - Street 1:2230 NW PETTYGROVE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2659
Practice Address - Country:US
Practice Address - Phone:503-223-6223
Practice Address - Fax:503-223-3665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR095570Medicaid
OR095570Medicaid