Healthcare Provider Details

I. General information

NPI: 1821153941
Provider Name (Legal Business Name): HEAD & NECK SURGICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1849 NW KEARNEY ST STE 300
PORTLAND OR
97209-1453
US

IV. Provider business mailing address

1849 NW KEARNEY ST SUITE 300
PORTLAND OR
97209-1453
US

V. Phone/Fax

Practice location:
  • Phone: 503-224-1371
  • Fax: 503-224-0722
Mailing address:
  • Phone: 503-224-1371
  • Fax: 503-224-0722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number StateOR

VIII. Authorized Official

Name: SHANNON GRESH
Title or Position: CLINIC OPERATIONS MANAGER
Credential:
Phone: 503-224-1371