Healthcare Provider Details

I. General information

NPI: 1629146121
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/04/2025
Certification Date: 07/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 VILLA RD SUITE 104
NEWBERG OR
97132-1886
US

IV. Provider business mailing address

PO BOX 31001 - 4180
PASADENA CA
91110-4180
US

V. Phone/Fax

Practice location:
  • Phone: 503-537-1508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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