Provider Demographics
NPI:1972813962
Name:COLUMBIA PAIN AND SPINE INSTITUTE
Entity Type:Organization
Organization Name:COLUMBIA PAIN AND SPINE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKSIMOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-915-9217
Mailing Address - Street 1:689 NW BURNSIDE ROAD
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8014
Mailing Address - Country:US
Mailing Address - Phone:503-382-8100
Mailing Address - Fax:503-382-8120
Practice Address - Street 1:689 NW BURNSIDE ROAD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-382-8100
Practice Address - Fax:503-382-8120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X
ORMD 28526261QP3300X
WAMD60054432261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500632340Medicaid
OR500632340Medicaid