Healthcare Provider Details

I. General information

NPI: 1841040292
Provider Name (Legal Business Name): NORTHWEST SPINE SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10,000 SE MAIN ST ST 360
PORTLAND OR
97216
US

IV. Provider business mailing address

10000 SE MAIN ST STE 360
PORTLAND OR
97216-2474
US

V. Phone/Fax

Practice location:
  • Phone: 503-253-4000
  • Fax: 503-253-4002
Mailing address:
  • Phone: 503-253-4000
  • Fax: 503-253-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: EMERALD LOUISE NELSON FLORES
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 971-277-0559