NPIMap

Organization Active NPI

Burnside Surgery Center LLC

  • Ambulatory Surgical Clinic/Center
  • Gresham, OR
National Provider Identifier
1013417351
Registry record updated May 23, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
License
07-1645 Issued in OR
Legal business name
BURNSIDE SURGERY CENTER LLC
Practice address
689 NW Burnside Rd FL 1
Gresham, OR 97030-3739
Phone
(503) 382-8140
NPI assigned
Feb 13, 2018
Last updated
May 23, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 23, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Oleg MaksimovNPI 1780796326
Title
Director
Phone
(503) 915-9217

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pain Medicine (Physical Medicine & Rehabilitation) Physician 2081P2900X MD28526 OR
Ambulatory Surgical Clinic/Center 261QA1903X 07-1645 OR Primary

Addresses

Primary practice location

689 NW Burnside Rd FL 1
Gresham, OR 97030-3739

Mailing address

689 NW Burnside Rd FL 1
Gresham, OR 97030-3739

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180522002433 OR Part B Supplier - Ambulatory Surgical Center 9032474051 Practice locations: Gresham, OR

Care Compare: Ambulatory surgical center

Medicare Care Compare
Listed as
Burnside Surgery CenterCCN 38C0001111
Medicare certification status
ActiveFrom the Provider of Services file

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
38D2150925Burnside Surgery Center689 NW Burnside Road, Gresham, OR 97030Certificate of waiverJul 5, 2028

National Provider Directory

National Provider Directory

Locations

689 NW Burnside Rd
Gresham, OR 97030
Phone (503) 382-8100

689 NW Burnside Rd
Fl 1
Gresham, OR 97030
Phone (503) 382-8140

Networks

  • devoted network organization-54bc88f0-8c1c-41b6-b022-755ebfe4d22c

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1518480000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1621728000000",
    "number": "1013417351",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "689 NW BURNSIDE RD FL 1",
            "city": "GRESHAM",
            "state": "OR",
            "postal_code": "970303739"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "689 NW BURNSIDE RD FL 1",
            "city": "GRESHAM",
            "state": "OR",
            "postal_code": "970303739",
            "telephone_number": "503-382-8140"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BURNSIDE SURGERY CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-02-13",
        "last_updated": "2021-05-23",
        "certification_date": "2021-05-23",
        "status": "A",
        "authorized_official_last_name": "MAKSIMOV",
        "authorized_official_first_name": "OLEG",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "503-915-9217",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "2081P2900X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation, Pain Medicine",
            "state": "OR",
            "license": "MD28526",
            "primary": false
        },
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "OR",
            "license": "07-1645",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Gresham, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 23, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.