Provider Demographics
NPI:1629774179
Name:NORTHWEST EXTREMITY SPECIALISTS LLC
Entity Type:Organization
Organization Name:NORTHWEST EXTREMITY SPECIALISTS LLC
Other - Org Name:NES ORTHOPEDICS
Other - Org Type:Other Name
Authorized Official - Title/Position:AREA OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHEADAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-352-1313
Mailing Address - Street 1:9115 SW OLESON RD STE 205
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6877
Mailing Address - Country:US
Mailing Address - Phone:503-245-2420
Mailing Address - Fax:503-245-2445
Practice Address - Street 1:9445 SW LOCUST ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6634
Practice Address - Country:US
Practice Address - Phone:503-245-2420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST EXTREMITY SPECIALISTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-02-06
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174973242OtherORTHOPEDIC