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General NPI Number Information
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NPI Number | 1215221205
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Entity Type | Organization
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Legal Business Name | WILLAMETTE UROLOGY PC
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Dates
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Enumeration Date | 06/07/2011
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Last Update Date | 06/07/2011
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Provider Practice Location Address
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Address Line | 591 SE CLAY ST
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City | DALLAS
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State | OR
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Zip | 97338-2812
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Country | US
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Telephone | 503-561-7100
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Fax | 503-561-7124
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Provider Business Mailing Address
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Address Line | 875 OAK ST SE SUITE 5030
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City | SALEM
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State | OR
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Zip | 97301-3975
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Country | US
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Telephone | 503-561-7100
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Fax | 503-561-7124
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. BRYCE CARMAN
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Credential |
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Telephone | 503-561-7112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 01954353
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License Number State | OR
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