MEDICARE: PROVIDENCE HEALTH & SERVICES - OREGON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center
2	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396836276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HEALTH & SERVICES - OREGON

Provider Business Mailing Address
First Line	:	PO BOX 31001 - 4180
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91110-4180
Country	:	US
Telephone Number	:	503-215-6494
Fax Number	:	503-215-6644

Provider Business Practice Location Address
First Line	:	12442 SW SCHOLLS FERRY RD
Second Line	:	SUITE 100
City	:	TIGARD
State	:	OR
Zip	:	97223-0803
Country	:	US
Telephone Number	:	503-216-9900
Fax Number	:	503-216-9266

Authorized Official
Title or Position	:	ASSISTANT SECRETARY ENROLLMENT
Name	:	DONALD WAYNE ANDERSON JR.
Credential	:
Telephone Number	:	425-358-9786

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/04/2025

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