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General NPI Number Information
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NPI Number | 1235195447
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Entity Type | Organization
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Legal Business Name | GRESHAM STATION SURGERY CENTER LLC
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Dates
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Enumeration Date | 04/25/2006
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Last Update Date | 05/04/2010
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Provider Practice Location Address
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Address Line | 831 NW COUNCIL DRIVE SUITE 212
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City | GRESHAM
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State | OR
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Zip | 97030
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Country | US
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Telephone | 503-907-1907
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Fax | 503-489-2073
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Provider Business Mailing Address
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Address Line | 831 NW COUNCIL DRIVE SUITE 212
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City | GRESHAM
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State | OR
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Zip | 97030
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Country | US
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Telephone | 503-907-1907
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Fax | 503-489-2073
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MICHAEL RAY SKINNER
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Credential | RN
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Telephone | 503-907-1907
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 394819
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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 | 07-1567
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License Number State | OR
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