MEDICARE: NORTHWEST AMBULATORY SURGERY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	07 1564	OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00722196	OTHER	OR	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1245482280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST AMBULATORY SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	14201 DALLAS PKWY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75254-2916
Country	:	US
Telephone Number	:	503-542-4888
Fax Number	:	503-542-2813

Provider Business Practice Location Address
First Line	:	1515 NW 18TH AVE
Second Line	:	STE 200
City	:	PORTLAND
State	:	OR
Zip	:	97209-2516
Country	:	US
Telephone Number	:	503-542-4888
Fax Number	:	503-542-2813

Authorized Official
Title or Position	:	OFFICER/AUTHORIZED OFFICIAL
Name	:	ERIC BOON
Credential	:
Telephone Number	:	480-567-0269

Provider Enumeration Date	:	10/22/2008
Last Update Date	:	10/14/2024

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