NPIMap

Organization Active NPI

Lake Grove ENT PC

  • Otolaryngology Physician
  • Lake Oswego, OR
National Provider Identifier
1043211824
Registry record updated Apr 4, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Otolaryngology PhysicianTaxonomy code 207Y00000X
Legal business name
LAKE GROVE ENT PC
Practice address
17704 Jean Way
Ste 101
Lake Oswego, OR 97035-5497
Phone
(503) 699-0370
Fax
(971) 236-9099
NPI assigned
Aug 3, 2005
Last updated
Apr 4, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 4, 2022

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

Authorized official

Name
Cheryl Lee Kruse
Title
Clinic Manager
Phone
(503) 699-0370

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Otolaryngology Physician 207Y00000X Primary

Addresses

Primary practice location

17704 Jean Way
Ste 101
Lake Oswego, OR 97035-5497

Mailing address

17704 Jean Way
Ste 101
Lake Oswego, OR 97035-5497
Phone (503) 699-0370

Other identifiers 1

IdentifierTypeStateIssuer
005809MedicaidOR

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060221000911 OR Part B Supplier - Clinic/Group Practice 9133135692 Receives reassigned benefits from 7 practitioners
Practice locations: Lake Oswego, OR

National Provider Directory

National Provider Directory

Locations

17704 Jean Way
Ste 101
Lake Oswego, OR 97035
Phone (503) 635-0897

Practitioners & affiliated clinicians

Practitioners 11

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.

NPI Registry JSON

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

{
    "created_epoch": "1123027200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1649030400000",
    "number": "1043211824",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17704 JEAN WAY",
            "address_2": "STE 101",
            "city": "LAKE OSWEGO",
            "state": "OR",
            "postal_code": "970355497",
            "telephone_number": "503-699-0370",
            "fax_number": "971-236-9099"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17704 JEAN WAY",
            "address_2": "STE 101",
            "city": "LAKE OSWEGO",
            "state": "OR",
            "postal_code": "970355497",
            "telephone_number": "503-699-0370",
            "fax_number": "971-236-9099"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE GROVE ENT PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-03",
        "last_updated": "2022-04-04",
        "certification_date": "2022-04-04",
        "status": "A",
        "authorized_official_last_name": "KRUSE",
        "authorized_official_first_name": "CHERYL",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "CLINIC MANAGER",
        "authorized_official_telephone_number": "503-699-0370"
    },
    "taxonomies": [
        {
            "code": "207Y00000X",
            "taxonomy_group": "",
            "desc": "Otolaryngology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "005809",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Oswego, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 4, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.