Healthcare Provider Details

I. General information

NPI: 1225567928
Provider Name (Legal Business Name): EASTSIDE ORTHOPEDICS & SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10121 SE SUNNYSIDE RD STE 100
CLACKAMAS OR
97015-5755
US

IV. Provider business mailing address

10121 SE SUNNYSIDE RD STE 100
CLACKAMAS OR
97015-5755
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-1769
  • Fax: 503-659-7522
Mailing address:
  • Phone: 503-659-1769
  • Fax: 503-659-7522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberMD183085
License Number StateOR

VIII. Authorized Official

Name: PAUL D RUESCH
Title or Position: MD/ PHYSICIAN
Credential: MD
Phone: 503-659-1964