Healthcare Provider Details

I. General information

NPI: 1396783023
Provider Name (Legal Business Name): PAIN RELIEF SPECIALIST NORTHWEST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNCIL DR SUITE 300
GRESHAM OR
97030-3721
US

IV. Provider business mailing address

831 NW COUNCIL DR SUITE 300
GRESHAM OR
97030-3721
US

V. Phone/Fax

Practice location:
  • Phone: 503-382-8100
  • Fax: 503-382-8120
Mailing address:
  • Phone: 503-382-8100
  • Fax: 503-382-8120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number648952
License Number StateOR

VIII. Authorized Official

Name: DR. EDWARD ALAN MCCLUSKEY
Title or Position: OWNER OPERATOR
Credential: MD
Phone: 503-382-8100