Provider Demographics
NPI:1649773490
Name:CORNELL PAIN CLINIC
Entity Type:Organization
Organization Name:CORNELL PAIN CLINIC
Other - Org Name:SURESH CHAND MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-376-9200
Mailing Address - Street 1:15455 NW GREENBRIER PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-8115
Mailing Address - Country:US
Mailing Address - Phone:503-376-9200
Mailing Address - Fax:
Practice Address - Street 1:15455 NW GREENBRIER PKWY STE 130
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006
Practice Address - Country:US
Practice Address - Phone:503-376-9200
Practice Address - Fax:503-376-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084P0800X
ORMD178982208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500710995Medicaid