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General NPI Number Information
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NPI Number | 1225567928
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Entity Type | Organization
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Legal Business Name | EASTSIDE ORTHOPEDICS & SPORTS MEDICINE, LLC
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Dates
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Enumeration Date | 06/06/2017
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Last Update Date | 02/11/2025
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Provider Practice Location Address
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Address Line | 6542 SE LAKE RD STE 201
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City | MILWAUKIE
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State | OR
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Zip | 97222-2245
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Country | US
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Telephone | 503-659-1769
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Fax | 503-659-7522
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Provider Business Mailing Address
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Address Line | 6542 SE LAKE RD STE 201
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City | MILWAUKIE
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State | OR
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Zip | 97222-2245
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Country | US
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Telephone | 503-659-1769
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Fax | 503-659-7522
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MRS. ANGELA ROBERTS
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Credential |
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Telephone | 503-659-1715
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0004X
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Taxonomy Name | Orthopaedic Foot and Ankle Surgery Physician
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License Number | MD183085
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number |
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License Number State |
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