Healthcare Provider Details

I. General information

NPI: 1235195447
Provider Name (Legal Business Name): GRESHAM STATION SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNCIL DRIVE SUITE 212
GRESHAM OR
97030
US

IV. Provider business mailing address

831 NW COUNCIL DRIVE SUITE 212
GRESHAM OR
97030
US

V. Phone/Fax

Practice location:
  • Phone: 503-907-1907
  • Fax: 503-489-2073
Mailing address:
  • Phone: 503-907-1907
  • Fax: 503-489-2073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number394819
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number07-1567
License Number StateOR

VIII. Authorized Official

Name: MICHAEL RAY SKINNER
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 503-907-1907