Healthcare Provider Details

I. General information

NPI: 1053419218
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 NW DIVISION ST
GRESHAM OR
97030-5506
US

IV. Provider business mailing address

PO BOX 31001 - 4180
PASADENA CA
91110-4180
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-9500
  • Fax: 503-215-9525
Mailing address:
  • Phone: 503-215-6494
  • Fax: 503-215-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier287333
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MR. DONALD W ANDERSON JR.
Title or Position: ASST SEC ENROLL
Credential:
Phone: 425-358-9786