Healthcare Provider Details

I. General information

NPI: 1013417351
Provider Name (Legal Business Name): BURNSIDE SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 05/23/2021
Certification Date: 05/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 NW BURNSIDE RD FL 1
GRESHAM OR
97030-3739
US

IV. Provider business mailing address

689 NW BURNSIDE RD FL 1
GRESHAM OR
97030-3739
US

V. Phone/Fax

Practice location:
  • Phone: 503-382-8140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD28526
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number07-1645
License Number StateOR

VIII. Authorized Official

Name: DR. OLEG MAKSIMOV
Title or Position: DIRECTOR
Credential:
Phone: 503-915-9217