Healthcare Provider Details

I. General information

NPI: 1457689598
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9290 SE SUNNYBROOK BLVD SUITE 210
CLACKAMAS OR
97015
US

IV. Provider business mailing address

PO BOX 4388
PORTLAND OR
97208-4388
US

V. Phone/Fax

Practice location:
  • Phone: 503-216-7960
  • Fax: 503-216-2823
Mailing address:
  • Phone: 503-216-7960
  • Fax: 503-215-6387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON JR.
Title or Position: ASSISTANT SECREATRY FOR ENROLLMENT
Credential:
Phone: 425-358-9786