Healthcare Provider Details

I. General information

NPI: 1255354700
Provider Name (Legal Business Name): LEGACY MOUNT HOOD MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24800 SE STARK ST
GRESHAM OR
97030-3378
US

IV. Provider business mailing address

PO BOX 4037
PORTLAND OR
97208-4037
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1122
  • Fax:
Mailing address:
  • Phone: 503-413-4048
  • Fax: 503-413-3212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number141337
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number14-1337
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier069526
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: SARAH JENSEN
Title or Position: VP FINANCE
Credential:
Phone: 503-415-5145