Provider Demographics
NPI:1013959493
Name:SALEM CARDIOLOGY ARRHYTHMIA DIVISION, P.C.
Entity Type:Organization
Organization Name:SALEM CARDIOLOGY ARRHYTHMIA DIVISION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-561-8550
Mailing Address - Street 1:PO BOX 665
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97075-0665
Mailing Address - Country:US
Mailing Address - Phone:503-561-8550
Mailing Address - Fax:503-561-8560
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:SUITE #5040
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3975
Practice Address - Country:US
Practice Address - Phone:503-561-8550
Practice Address - Fax:503-561-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17813207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288256Medicaid
ORR134731Medicare PIN
ORR138646Medicare PIN