Provider Demographics
NPI:1316436785
Name:NICHOLAS FOGELSON MD LLC
Entity type:Organization
Organization Name:NICHOLAS FOGELSON MD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:FOGELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-715-1377
Mailing Address - Street 1:511 SW 10TH AVE STE 907
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2710
Mailing Address - Country:US
Mailing Address - Phone:503-715-1377
Mailing Address - Fax:503-771-2717
Practice Address - Street 1:511 SW 10TH AVE STE 907
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2710
Practice Address - Country:US
Practice Address - Phone:503-715-1377
Practice Address - Fax:503-771-2717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR173545207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty