Provider Demographics
NPI:1356726418
Name:ADVANCED VASCULAR THERAPY LLC
Entity type:Organization
Organization Name:ADVANCED VASCULAR THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROSEBOROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-371-1756
Mailing Address - Street 1:2480 LIBERTY ST NE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-8380
Mailing Address - Country:US
Mailing Address - Phone:503-371-1756
Mailing Address - Fax:
Practice Address - Street 1:2480 LIBERTY ST NE
Practice Address - Street 2:SUITE 110
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-8380
Practice Address - Country:US
Practice Address - Phone:503-371-1756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1501902086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR599512556Medicaid
OR599512556Medicaid