Organization
ADVANCED VASCULAR THERAPY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GLEN S ROSEBOROUGH M.D. (DIRECTOR)
(503) 371-1756
Entity
Organization
Contact information
Practice address
2480 LIBERTY ST NE, SUITE 110, SALEM, OR 97301-8380
(503) 371-1756
Mailing address
2480 LIBERTY ST NE, SUITE 110, SALEM, OR 97301-8380
(503) 371-1756
Taxonomy
Speciality
Code
Description
License number
State
2086S0129X
Vascular Surgery Physician
Primary
MD150190
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
599512556
—
OR
Enumeration date
07/29/2015
Last updated
11/20/2015
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