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	313M00000X	Nursing Facility/Intermediate Care Facility	385018	OR
2	314000000X	Skilled Nursing Facility	385018	OR

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	:	1417978164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HEALTH & SERVICES OREGON

Provider Business Mailing Address
First Line	:	540 S MAIN ST
Second Line	:
City	:	MOUNT ANGEL
State	:	OR
Zip	:	97362-9540
Country	:	US
Telephone Number	:	503-845-6841
Fax Number	:	503-845-9229

Provider Business Practice Location Address
First Line	:	540 S MAIN ST
Second Line	:
City	:	MOUNT ANGEL
State	:	OR
Zip	:	97362-9540
Country	:	US
Telephone Number	:	503-845-6841
Fax Number	:	503-845-9229

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

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	05/15/2025

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Directions to “PROVIDENCE HEALTH & SERVICES OREGON ” Practice Location

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