Healthcare Provider Details

I. General information

NPI: 1982977849
Provider Name (Legal Business Name): WILLAMETTE PAIN AND SPINE CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 8TH AVE SUITE 200
WEST LINN OR
97068-4657
US

IV. Provider business mailing address

2020 8TH AVE SUITE 200
WEST LINN OR
97068-4657
US

V. Phone/Fax

Practice location:
  • Phone: 503-512-1212
  • Fax: 503-512-1220
Mailing address:
  • Phone: 503-512-1212
  • Fax: 503-512-1220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD26192
License Number StateOR

VIII. Authorized Official

Name: GREGORY GULLO
Title or Position: PRESIDENT
Credential: MD
Phone: 503-512-1212