Healthcare Provider Details

I. General information

NPI: 1770516544
Provider Name (Legal Business Name): NORTHWEST SURGICAL SPECIALISTS LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 RIVERBEND DR STE 300
SPRINGFIELD OR
97477
US

IV. Provider business mailing address

3355 RIVERBEND DR STE 300
SPRINGFIELD OR
97477-8800
US

V. Phone/Fax

Practice location:
  • Phone: 541-868-9303
  • Fax: 541-868-9306
Mailing address:
  • Phone: 541-868-9303
  • Fax: 541-868-9306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: GINA MULLEN
Title or Position: MANAGER
Credential:
Phone: 541-868-9377