Healthcare Provider Details

I. General information

NPI: 1114015971
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9205 SW BARNES RD
PORTLAND OR
97225-6603
US

IV. Provider business mailing address

PO BOX 3396
PORTLAND OR
97208-3396
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-4323
  • Fax: 503-215-0297
Mailing address:
  • Phone: 503-215-4323
  • Fax: 503-215-0297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD W ANDERSON JR.
Title or Position: ASST SEC FOR ENROLL/DIR REIMB ADMIN
Credential:
Phone: 425-525-5392