=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396783023
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAIN RELIEF SPECIALIST NORTHWEST PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 05/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 831 NW COUNCIL DR SUITE 300
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97030-3721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-382-8100
-----------------------------------------------------
Fax | 503-382-8120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 831 NW COUNCIL DR SUITE 300
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97030-3721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-382-8100
-----------------------------------------------------
Fax | 503-382-8120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER OPERATOR
-----------------------------------------------------
Name | DR. EDWARD ALAN MCCLUSKEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 503-382-8100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 648952
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------