=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376571364
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST DERMATOLOGY & LASER CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2006
-----------------------------------------------------
Last Update Date | 06/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1130 NW 22ND AVE STE 330
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97210-2970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-295-2366
-----------------------------------------------------
Fax | 503-295-3065
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 23200
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97281-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-968-4620
-----------------------------------------------------
Fax | 503-968-2779
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BERT G TAVELLI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 503-295-2366
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | MD14681
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------