Healthcare Provider Details

I. General information

NPI: 1013197987
Provider Name (Legal Business Name): CENTER FOR MENS AND WOMENS UROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 12/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24076 SE STARK ST SUITE 310
GRESHAM OR
97030-3373
US

IV. Provider business mailing address

24076 SE STARK ST SUITE 310
GRESHAM OR
97030-3373
US

V. Phone/Fax

Practice location:
  • Phone: 503-492-6510
  • Fax: 503-492-6502
Mailing address:
  • Phone: 503-492-6510
  • Fax: 503-492-6502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SHAMMAI ROCKOVE
Title or Position: MEDICAL DRIECTOR
Credential: M.D.
Phone: 503-492-6510