Provider Demographics
NPI:1851825566
Name:MODERN NOSE CLINIC LLC
Entity type:Organization
Organization Name:MODERN NOSE CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SKARADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-584-1174
Mailing Address - Street 1:340 VISTA AVE SE
Mailing Address - Street 2:STE 100
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-584-1174
Mailing Address - Fax:503-584-1330
Practice Address - Street 1:340 VISTA AVE SE
Practice Address - Street 2:STE 100
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-584-1174
Practice Address - Fax:503-584-1330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23186207Y00000X
207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287190Medicaid
110381Medicare PIN
OR287190Medicaid