Provider Demographics
NPI:1396783023
Name:PAIN RELIEF SPECIALIST NORTHWEST PC
Entity type:Organization
Organization Name:PAIN RELIEF SPECIALIST NORTHWEST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MCCLUSKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-382-8100
Mailing Address - Street 1:831 NW COUNCIL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3721
Mailing Address - Country:US
Mailing Address - Phone:503-382-8100
Mailing Address - Fax:503-382-8120
Practice Address - Street 1:831 NW COUNCIL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3721
Practice Address - Country:US
Practice Address - Phone:503-382-8100
Practice Address - Fax:503-382-8120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR648952208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1391489OtherHEALTH CARE RESOURCES NW
CK2353OtherRR MEDICARE
WAO166607OtherLABOR & IND
808594000OtherREGENCE
307446OtherMHN
OR130333Medicaid
WA7118037Medicaid
307446OtherMHN
1391489OtherHEALTH CARE RESOURCES NW