Provider Demographics
NPI:1639158611
Name:WILLAMETTE VALLEY FOOT & ANKLE CENTER PC
Entity Type:Organization
Organization Name:WILLAMETTE VALLEY FOOT & ANKLE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-435-0130
Mailing Address - Street 1:212 NE NORTON LN
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-8470
Mailing Address - Country:US
Mailing Address - Phone:503-435-0130
Mailing Address - Fax:503-435-0145
Practice Address - Street 1:212 NE NORTON LN
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-8470
Practice Address - Country:US
Practice Address - Phone:503-435-0130
Practice Address - Fax:503-435-0145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231897Medicaid
OR231897Medicaid
ORR115536Medicare ID - Type Unspecified
U76993Medicare UPIN