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General NPI Number Information
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NPI Number | 1013417351
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Entity Type | Organization
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Legal Business Name | BURNSIDE SURGERY CENTER LLC
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Dates
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Enumeration Date | 02/13/2018
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Last Update Date | 05/23/2021
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Provider Practice Location Address
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Address Line | 689 NW BURNSIDE RD FL 1
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City | GRESHAM
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State | OR
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Zip | 97030-3739
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Country | US
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Telephone | 503-382-8140
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Fax |
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Provider Business Mailing Address
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Address Line | 689 NW BURNSIDE RD FL 1
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City | GRESHAM
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State | OR
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Zip | 97030-3739
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. OLEG MAKSIMOV
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Credential |
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Telephone | 503-915-9217
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | MD28526
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 07-1645
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License Number State | OR
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