Provider Demographics
NPI:1659638872
Name:R TYSON SCOTT DPM LLC
Entity Type:Organization
Organization Name:R TYSON SCOTT DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:TYSON
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-370-8784
Mailing Address - Street 1:800 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4137
Mailing Address - Country:US
Mailing Address - Phone:503-370-8784
Mailing Address - Fax:503-362-4017
Practice Address - Street 1:800 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-370-8784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP154513261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR160213Medicare PIN