Healthcare Provider Details

I. General information

NPI: 1386713972
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1698 E MCANDREWS RD SUITE 300
MEDFORD OR
97504-5589
US

IV. Provider business mailing address

PO BOX 31001 - 4180
PASADENA CA
91110-4180
US

V. Phone/Fax

Practice location:
  • Phone: 541-732-7950
  • Fax: 541-732-7901
Mailing address:
  • Phone: 425-358-9786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

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