Provider Demographics
NPI:1134874001
Name:WILLAMETTE ORTHOPEDIC GROUP, LLC
Entity type:Organization
Organization Name:WILLAMETTE ORTHOPEDIC GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LORISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADDABBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-540-6300
Mailing Address - Street 1:1600 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4257
Mailing Address - Country:US
Mailing Address - Phone:503-540-6300
Mailing Address - Fax:503-540-6404
Practice Address - Street 1:591 SE CLAY ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-2812
Practice Address - Country:US
Practice Address - Phone:503-540-6300
Practice Address - Fax:503-540-6404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-18
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278220Medicaid