Provider Demographics
NPI:1386713972
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASST CORP SECRETARY FOR ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
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:
Mailing Address - Fax:
Practice Address - Street 1:1698 E MCANDREWS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5589
Practice Address - Country:US
Practice Address - Phone:541-732-7950
Practice Address - Fax:541-732-7901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288499Medicaid
ORCG6801OtherRAILROAD MEDICARE
OR288499Medicaid