Provider Demographics
NPI:1861429227
Name:SHILEY, SAMUEL GARDNER (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:GARDNER
Last Name:SHILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:2222 NW LOVEJOY ST
Practice Address - Street 2:SUITE #622
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3033
Practice Address - Country:US
Practice Address - Phone:503-229-8455
Practice Address - Fax:503-229-7028
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25260207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269657Medicaid
WA2059958Medicaid
OR187103Medicare PIN
ORP01742158Medicare PIN
WA2059958Medicaid