Provider Demographics
NPI:1972757870
Name:UNIVERSITY PROFESSIONAL SERVICES
Entity type:Organization
Organization Name:UNIVERSITY PROFESSIONAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DEAN
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MASCIOTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-494-5099
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:MAIL CODE MBS
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-8300
Mailing Address - Fax:
Practice Address - Street 1:3101 E STATE ST
Practice Address - Street 2:SUITE 2107
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6232
Practice Address - Country:US
Practice Address - Phone:208-473-3003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY PROFESSIONAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-05
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1370134Medicare PIN