Organization
WILLAMETTE GENERAL & COLON-RECTAL SURGERY PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRENT K EVETTS M.D. (OWNER/PHYSICIAN)
(503) 691-1743
Entity
Organization
Contact information
Practice address
19875 SW 65TH AVE, SUITE 260, TUALATIN, OR 97062-8353
(503) 691-1743
(503) 691-0983
Mailing address
19875 SW 65TH AVE, SUITE 260, TUALATIN, OR 97062-8353
(503) 691-1743
(503) 691-0983
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MD20653
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000035001
BLUE CROSS
OR
01
—
1375470
UNITED HEALTHCARE
OR
05
—
150330
—
OR
01
—
3007286-01
MHN
OR
01
—
R105002
MEDICARE PTAN
OR
Enumeration date
11/04/2005
Last updated
09/09/2014
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