Provider Demographics
NPI:1538174461
Name:ELISA A. BURGESS, MD, PC
Entity type:Organization
Organization Name:ELISA A. BURGESS, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-691-6201
Mailing Address - Street 1:3439 NE SANDY BLVD
Mailing Address - Street 2:PMB 375
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1959
Mailing Address - Country:US
Mailing Address - Phone:503-284-8841
Mailing Address - Fax:503-282-3302
Practice Address - Street 1:16865 BOONES FERRY RD
Practice Address - Street 2:STE 101
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5252
Practice Address - Country:US
Practice Address - Phone:503-699-6464
Practice Address - Fax:503-699-6939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18936208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR262368Medicaid
OR262368Medicaid
ORR110016Medicare PIN