Basic Information
| Provider Information | |||||||||
| NPI: | 1538174461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELISA A. BURGESS, MD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3439 NE SANDY BLVD | ||||||||
| Address2: | PMB 375 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032848841 | ||||||||
| FaxNumber: | 5032823302 | ||||||||
| Practice Location | |||||||||
| Address1: | 16865 BOONES FERRY RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970355252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036996464 | ||||||||
| FaxNumber: | 5036996939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | BURGESS | ||||||||
| AuthorizedOfficialFirstName: | ELISA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5036916201 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | MD18936 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 262368 | 05 | OR | MEDICAID |