Provider Demographics
NPI:1710023247
Name:OREGON SCOTTISH RITE CLINICS
Entity Type:Organization
Organization Name:OREGON SCOTTISH RITE CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD SLP
Authorized Official - Phone:503-226-1048
Mailing Address - Street 1:4201 NE 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-4211
Mailing Address - Country:US
Mailing Address - Phone:503-282-2412
Mailing Address - Fax:
Practice Address - Street 1:5125 SW MACADAM AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3809
Practice Address - Country:US
Practice Address - Phone:503-226-1048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR235Z00000X251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR838353006OtherBLUECROSS
OR247347Medicaid