Healthcare Provider Details

I. General information

NPI: 1114009628
Provider Name (Legal Business Name): PORTLAND VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW SAM JACKSON ROAD
PORTLAND OR
97207-1034
US

IV. Provider business mailing address

PO BOX 1034
PORTLAND OR
97207-1034
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberL3442
License Number StateOR

VIII. Authorized Official

Name: SUSAN PLENNES SCHUSTER
Title or Position: SOCIAL WORKER
Credential: LCSW
Phone: 503-220-8262