Healthcare Provider Details

I. General information

NPI: 1437442795
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 07/04/2025
Certification Date: 07/04/2025
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: 503-962-1000
  • Fax: 503-963-3005
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier500639264
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: DONALD W ANDERSON JR.
Title or Position: ASSISTANT SECRETARY ENROLLMENT
Credential:
Phone: 425-358-9786