Provider Demographics
NPI:1992882500
Name:PROVIDENCE HEALTH & SERVICES - OREGON
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - OREGON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
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:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:205 N PHOENIX RD
Practice Address - Street 2:SUITE A
Practice Address - City:PHOENIX
Practice Address - State:OR
Practice Address - Zip Code:97535-9104
Practice Address - Country:US
Practice Address - Phone:541-732-5760
Practice Address - Fax:541-732-3406
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES - OREGON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278307Medicaid
ORCG6801OtherRAIL ROAD MEDIARE
ORR105969Medicare PIN