Provider Demographics
NPI:1952567653
Name:OREGON UROLOGY CLINIC, P.C.
Entity Type:Organization
Organization Name:OREGON UROLOGY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROSENCRANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-229-7722
Mailing Address - Street 1:2222 NW LOVEJOY STREET SUITE 416
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5102
Mailing Address - Country:US
Mailing Address - Phone:503-229-7722
Mailing Address - Fax:503-222-5679
Practice Address - Street 1:3100 NE 28TH STREET SUITE C
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-4518
Practice Address - Country:US
Practice Address - Phone:503-229-7722
Practice Address - Fax:503-222-5679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD07089208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287875Medicaid
OR38D1047175OtherCLIA ID#
OR38D1047175OtherCLIA ID#
OR136962Medicare PIN