Provider Demographics
NPI:1033345012
Name:PROVIDENCE ST VINCENT MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENCE ST VINCENT MEDICAL CENTER
Other - Org Name:PROVIDENCE INTEGRATIVE MEDICINE WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NOONAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-216-4657
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9135 SW BARNES RD
Practice Address - Street 2:SUITE 161
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6601
Practice Address - Country:US
Practice Address - Phone:503-216-0246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE ST VINCENT MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center