Healthcare Provider Details

I. General information

NPI: 1790653863
Provider Name (Legal Business Name): PROFESSIONAL RADIOLOGY OF OREGON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9115 SW OLESON RD
PORTLAND OR
97223-6875
US

IV. Provider business mailing address

9115 SW OLESON RD
PORTLAND OR
97223-6875
US

V. Phone/Fax

Practice location:
  • Phone: 954-927-1776
  • Fax:
Mailing address:
  • Phone: 954-927-1776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK GRNJA
Title or Position: PRESIDENT
Credential:
Phone: 954-927-1776