Provider Demographics
NPI:1396775672
Name:EASTMORELAND SURGICAL CLINIC
Entity type:Organization
Organization Name:EASTMORELAND SURGICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MADORIN
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-232-2163
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-0610
Mailing Address - Country:US
Mailing Address - Phone:503-963-1200
Mailing Address - Fax:425-259-6300
Practice Address - Street 1:2804 SE STEELE ST # 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-4525
Practice Address - Country:US
Practice Address - Phone:503-232-2163
Practice Address - Fax:503-232-2164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8107633OtherDSHS
8107633OtherDSHS
R00WCJTWBMedicare ID - Type Unspecified