Provider Demographics
NPI:1194751735
Name:SPINAL DIAGNOSTICS PC
Entity type:Organization
Organization Name:SPINAL DIAGNOSTICS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-885-1515
Mailing Address - Street 1:6464 SW BORLAND RD
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062
Mailing Address - Country:US
Mailing Address - Phone:503-885-1515
Mailing Address - Fax:503-885-1520
Practice Address - Street 1:6464 SW BORLAND RD
Practice Address - Street 2:SUITE A-2
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-885-1515
Practice Address - Fax:503-885-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10922174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDP9470OtherRAILROAD MEDICARE GROUP PIN
DP9470OtherRR MEDICARE
DP9470OtherRR MEDICARE
ORDP9470OtherRAILROAD MEDICARE GROUP PIN