Provider Demographics
NPI:1912045154
Name:CROISAN RIDGE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:CROISAN RIDGE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD PRESIDENT
Authorized Official - Phone:503-315-4977
Mailing Address - Street 1:4999 SKYLINE RD S # 150
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-2009
Mailing Address - Country:US
Mailing Address - Phone:503-315-4977
Mailing Address - Fax:503-584-7856
Practice Address - Street 1:4999 SKYLINE RD S # 150
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-2009
Practice Address - Country:US
Practice Address - Phone:503-315-4977
Practice Address - Fax:503-584-7856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1557261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R120517Medicare PIN