Healthcare Provider Details

I. General information

NPI: 1356609374
Provider Name (Legal Business Name): ALEXANDRA CERUTTI BOLOGNESE MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

117 S HAMILTON ST
MADISON WI
53703-4314
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-7810
  • Fax: 503-494-5292
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number73045
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD210833
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number73045
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberMD210833
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: