Provider Demographics
NPI:1245482280
Name:NORTHWEST AMBULATORY SURGERY CENTER LLC
Entity type:Organization
Organization Name:NORTHWEST AMBULATORY SURGERY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-567-0269
Mailing Address - Street 1:14201 DALLAS PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2916
Mailing Address - Country:US
Mailing Address - Phone:503-542-4888
Mailing Address - Fax:503-542-2813
Practice Address - Street 1:1515 NW 18TH AVE
Practice Address - Street 2:STE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2516
Practice Address - Country:US
Practice Address - Phone:503-542-4888
Practice Address - Fax:503-542-2813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07 1564261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00722196OtherRAILROAD MEDICARE
ORR145327Medicare PIN
OR38C0001067Medicare Oscar/Certification