Provider Demographics
NPI:1164522496
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:ASSISTANT SECRETARY OF 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:425-358-9786
Mailing Address - Street 1:PO BOX 31001 - 4180
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-4180
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:4920 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-3653
Practice Address - Country:US
Practice Address - Phone:503-215-3300
Practice Address - Fax:503-215-3350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022845Medicaid
OR022845Medicaid