Healthcare Provider Details

I. General information

NPI: 1558693291
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2010
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 ROYAL AVE SUITE 120
MEDFORD OR
97504-6461
US

IV. Provider business mailing address

PO BOX 5936 B
PORTLAND OR
97228-5936
US

V. Phone/Fax

Practice location:
  • Phone: 541-732-5566
  • Fax: 541-732-5503
Mailing address:
  • Phone: 503-215-4663
  • Fax: 503-215-4655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State

VIII. Authorized Official

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