Provider Demographics
NPI:1710106687
Name:MT HOOD GENERAL AND VASCULAR SURGEONS LLC
Entity Type:Organization
Organization Name:MT HOOD GENERAL AND VASCULAR SURGEONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-636-0776
Mailing Address - Street 1:17040 PILKINGTON RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5587
Mailing Address - Country:US
Mailing Address - Phone:503-661-4526
Mailing Address - Fax:503-675-5101
Practice Address - Street 1:17040 PILKINGTON RD
Practice Address - Street 2:SUITE 208
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5587
Practice Address - Country:US
Practice Address - Phone:503-636-0776
Practice Address - Fax:503-675-5101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11822208600000X
ORMD118072086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
R111152Medicare PIN
H51770Medicare UPIN
ORC93135Medicare UPIN
ORD94342Medicare UPIN