Healthcare Provider Details

I. General information

NPI: 1013437862
Provider Name (Legal Business Name): WILLAMETTE ORTHOPEDIC GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 06/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 NE NORTON LN
MCMINNVILLE OR
97128-8470
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 TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MRS. LORISSA ADDABBO
Title or Position: CEO
Credential: CEO
Phone: 503-540-6470