Provider Demographics
NPI:1003991845
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:PROVIDENCE PORTLAND MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST SEC FOR ENROLL/DIR REIMB ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 3395
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3395
Mailing Address - Country:US
Mailing Address - Phone:503-215-4323
Mailing Address - Fax:503-215-0297
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-4323
Practice Address - Fax:503-215-0297
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES OREGON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-26
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR824986000OtherREGENCE CLINIC NUMBER
ORCP7961OtherRAILROAD MEDICARE
OR138006100OtherREGENCE HOSPITAL NUMBER
OR150300Medicaid
OR050000000001OtherPROVIDENCE HEALTH PLAN
OR135983OtherMEDICAID BHS OUTPT
OR3358009OtherWASHINGTON MEDICAID
OR83917OtherWA DEPT OF LABOR CLINIC
OR5788OtherWA DEPT OF LABOR HOSPITAL
OR194075800OtherUS DEPT OF LABOR WC
OR138006100OtherREGENCE HOSPITAL NUMBER
ORCP7961OtherRAILROAD MEDICARE