Healthcare Provider Details

I. General information

NPI: 1134874001
Provider Name (Legal Business Name): WILLAMETTE ORTHOPEDIC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 SE CLAY ST
DALLAS OR
97338-2812
US

IV. Provider business mailing address

1600 STATE ST
SALEM OR
97301-4257
US

V. Phone/Fax

Practice location:
  • Phone: 503-540-6300
  • Fax: 503-540-6404
Mailing address:
  • Phone: 503-540-6300
  • Fax: 503-540-6404

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 Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LORISSA ADDABBO
Title or Position: CEO
Credential:
Phone: 503-540-6300