Healthcare Provider Details

I. General information

NPI: 1548545817
Provider Name (Legal Business Name): CASCADE CARDIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 COMMERCIAL ST SE SUITE 130
SALEM OR
97301-3421
US

IV. Provider business mailing address

777 COMMERCIAL ST SE SUITE 130
SALEM OR
97301-3421
US

V. Phone/Fax

Practice location:
  • Phone: 503-485-4787
  • Fax: 203-485-4789
Mailing address:
  • Phone: 503-485-4787
  • Fax: 203-485-4789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: HELEN C WIGSTROM
Title or Position: CREDENTAILING SPECIALIST
Credential:
Phone: 503-485-4787