Healthcare Provider Details

I. General information

NPI: 1093976243
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 CRATER LAKE AVE
MEDFORD OR
97504-6241
US

IV. Provider business mailing address

PO BOX 31001-4199
PASADENA CA
91110-4199
US

V. Phone/Fax

Practice location:
  • Phone: 541-732-5250
  • Fax: 541-732-5251
Mailing address:
  • Phone: 541-732-5250
  • Fax: 541-732-5251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateOR

VIII. Authorized Official

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