Provider Demographics
NPI:1154539203
Name:PROVIDENCE HEALTH & SERVICES
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:K
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:CMSC
Authorized Official - Phone:503-215-6631
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:1510 DIVISION ST STE 200
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1599
Practice Address - Country:US
Practice Address - Phone:503-650-6880
Practice Address - Fax:503-650-6888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067983Medicaid