Healthcare Provider Details

I. General information

NPI: 1649536509
Provider Name (Legal Business Name): SETH JAMES MASARU PALESCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD OHSU
PORTLAND OR
97239
US

IV. Provider business mailing address

62630 NW MT THIELSEN DR
BEND OR
97703-8501
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-8211
  • Fax:
Mailing address:
  • Phone: 843-810-7017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD176573
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: