NPIMap

Organization Active NPI

Advanced Vascular Therapy LLC

  • Vascular Surgery Physician
  • Salem, OR
National Provider Identifier
1356726418
Registry record updated Nov 20, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Vascular Surgery PhysicianTaxonomy code 2086S0129X
License
MD150190 Issued in OR
Legal business name
ADVANCED VASCULAR THERAPY LLC
Practice address
2480 Liberty St NE
Suite 110
Salem, OR 97301-8380
Phone
(503) 371-1756
NPI assigned
Jul 29, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 20, 2015

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

Authorized official

Name
Glen S Roseborough, M.D.
Title
Director
Phone
(503) 371-1756

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Vascular Surgery PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2086S0129X MD150190 OR Primary

Addresses

Primary practice location

2480 Liberty St NE
Suite 110
Salem, OR 97301-8380

Mailing address

2480 Liberty St NE
Suite 110
Salem, OR 97301-8380
Phone (503) 371-1756

Other identifiers 1

IdentifierTypeStateIssuer
599512556MedicaidOR

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1438128000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1447977600000",
    "number": "1356726418",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2480 LIBERTY ST NE",
            "address_2": "SUITE 110",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973018380",
            "telephone_number": "503-371-1756"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2480 LIBERTY ST NE",
            "address_2": "SUITE 110",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973018380",
            "telephone_number": "503-371-1756"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ADVANCED VASCULAR THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-07-29",
        "last_updated": "2015-11-20",
        "status": "A",
        "authorized_official_last_name": "ROSEBOROUGH",
        "authorized_official_first_name": "GLEN",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "503-371-1756",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "2086S0129X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Surgery, Vascular Surgery",
            "state": "OR",
            "license": "MD150190",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "599512556",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Salem, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 20, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.