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General NPI Number Information
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NPI Number | 1093976243
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Entity Type | Organization
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Legal Business Name | PROVIDENCE HEALTH & SERVICES - OREGON
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Dates
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Enumeration Date | 06/20/2008
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Last Update Date | 05/29/2025
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Provider Practice Location Address
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Address Line | 1111 CRATER LAKE AVE
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City | MEDFORD
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State | OR
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Zip | 97504-6241
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Country | US
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Telephone | 541-732-5250
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Fax | 541-732-5251
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Provider Business Mailing Address
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Address Line | PO BOX 31001-4199
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City | PASADENA
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State | CA
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Zip | 91110-4199
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Country | US
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Telephone | 541-732-5250
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Fax | 541-732-5251
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Authorized Official
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Title or Position | ASSISTANT SECRETARY OF ENROLLMENTS
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Name | DONALD W ANDERSON JR.
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Credential |
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Telephone | 425-358-9786
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | OR
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