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General NPI Number Information
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NPI Number | 1861900516
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Entity Type | Organization
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Legal Business Name | CORNELL PAIN CLINIC LLC
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Dates
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Enumeration Date | 01/16/2018
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Last Update Date | 06/28/2018
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Provider Practice Location Address
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Address Line | 15455 NW GREENBRIER PKWY STE 130
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City | BEAVERTON
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State | OR
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Zip | 97006
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Country | US
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Telephone | 503-376-9200
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Fax | 503-376-9201
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Provider Business Mailing Address
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Address Line | 15455 NW GREENBRIER PKWY STE 130
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City | BEAVERTON
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State | OR
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Zip | 97006-8115
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Country | US
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Telephone | 503-376-9200
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Fax | 503-376-9201
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. SURESH CHAND
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Credential | MD
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Telephone | 503-376-9200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | MD178982
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License Number State | OR
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Legacy Identifiers
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Identifier #1
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Identifier Code | 500710995
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Identifier Type | MEDICAID
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Identifier State | OR
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Identifier Issuer |
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 500710995
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Identifier Type | MEDICAID
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Identifier State | OR
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Identifier Issuer |
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