Healthcare Provider Details

I. General information

NPI: 1942926258
Provider Name (Legal Business Name): WILLAMETTE ORTHOPEDIC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 SE MILLER AVE
DALLAS OR
97338-2634
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 TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JULIA SHIELDS
Title or Position: CREDENTIALING SPECALIST
Credential:
Phone: 503-540-6470