Healthcare Provider Details

I. General information

NPI: 1588955314
Provider Name (Legal Business Name): WILLAMETTE ORTHOPEDIC GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 05/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 STATE ST
SALEM OR
97301-4257
US

IV. Provider business mailing address

1600 STATE ST
SALEM OR
97301-4257
US

V. Phone/Fax

Practice location:
  • Phone: 503-540-6300
  • Fax: 503-540-6404
Mailing address:
  • Phone: 503-540-6300
  • Fax: 503-540-6404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MISS DAVID L SCHLACTUS
Title or Position: CEO
Credential:
Phone: 503-315-7338