Provider Demographics
NPI:1427164516
Name:WESTSIDE PODIATRY CLINIC LLC
Entity type:Organization
Organization Name:WESTSIDE PODIATRY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:R
Authorized Official - Last Name:SURRATT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-245-2420
Mailing Address - Street 1:9900 SW HALL BLVD
Mailing Address - Street 2:SUIT 100
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223
Mailing Address - Country:US
Mailing Address - Phone:503-245-2420
Mailing Address - Fax:503-245-2445
Practice Address - Street 1:9900 SW HALL BLVD
Practice Address - Street 2:SUIT 100
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:503-245-2420
Practice Address - Fax:503-245-2445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
117798Medicare ID - Type Unspecified
OR5016770001Medicare NSC