Healthcare Provider Details

I. General information

NPI: 1013944776
Provider Name (Legal Business Name): PROVIDENCE MEDFORD MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 CRATER LAKE AVENUE
MEDFORD OR
97504-6214
US

IV. Provider business mailing address

P.O. BOX 3308
PORTLAND OR
97208-3308
US

V. Phone/Fax

Practice location:
  • Phone: 541-732-5000
  • Fax: 541-732-5131
Mailing address:
  • Phone: 503-215-4050
  • Fax: 503-215-4343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number140734
License Number StateOR

VIII. Authorized Official

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