=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922558063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GSO EQUIPMENT CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2016
-----------------------------------------------------
Last Update Date | 09/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19250 SW 90TH AVE
-----------------------------------------------------
City | TUALATIN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97062-7585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-692-3750
-----------------------------------------------------
Fax | 503-963-2825
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 541 NE 20TH AVE STE 225
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97232-2895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-963-2801
-----------------------------------------------------
Fax | 503-963-2825
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RICHARD JAMISON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 503-963-2801
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0800X
-----------------------------------------------------
Taxonomy Name | Endoscopy Clinic/Center
-----------------------------------------------------
License Number | 07-1624
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------