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General NPI Number Information
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NPI Number | 1316024128
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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 | 11/01/2006
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Last Update Date | 11/19/2025
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Provider Practice Location Address
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Address Line | 840 ROYAL AVE SUITE 110
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City | MEDFORD
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State | OR
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Zip | 97504-6461
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Country | US
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Telephone | 541-732-8370
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Fax | 541-732-8371
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Provider Business Mailing Address
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Address Line | PO BOX 31001 - 4180
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City | PASADENA
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State | CA
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Zip | 91110-4180
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Country | US
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Telephone | 503-215-6494
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Fax |
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Authorized Official
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Title or Position | ASSISTANT SECRETARY ENROLLMENT
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Name | DONALD WAYNE 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 |
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number |
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License Number State |
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