Provider Demographics
NPI:1750416848
Name:NORTHWEST NEUROLOGY CLINIC
Entity type:Organization
Organization Name:NORTHWEST NEUROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GAJANAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NILAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-652-2487
Mailing Address - Street 1:10202 SE 32ND AVE
Mailing Address - Street 2:SUITE 703
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-3625
Mailing Address - Country:US
Mailing Address - Phone:503-652-2487
Mailing Address - Fax:503-652-2597
Practice Address - Street 1:10202 SE 32ND AVE
Practice Address - Street 2:SUITE 703
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-3625
Practice Address - Country:US
Practice Address - Phone:503-652-2487
Practice Address - Fax:503-652-2597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14509174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130708Medicaid
OR130708Medicaid
ORB58774Medicare UPIN