Provider Demographics
NPI:1821153941
Name:HEAD & NECK SURGICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:HEAD & NECK SURGICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-224-1371
Mailing Address - Street 1:1849 NW KEARNEY ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1453
Mailing Address - Country:US
Mailing Address - Phone:503-224-1371
Mailing Address - Fax:503-224-0722
Practice Address - Street 1:1849 NW KEARNEY ST STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1453
Practice Address - Country:US
Practice Address - Phone:503-224-1371
Practice Address - Fax:503-224-0722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR204E00000X, 207YX0901X, 207YP0228X, 207YX0901X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Multi-Specialty
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Multi-Specialty
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286589Medicaid
OR286589Medicaid