Provider Demographics
NPI:1235259532
Name:PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - OREGON
Other - Org Name:PROVIDENCE ST VINCENT DEPARTMENT OF MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANDKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-216-2229
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 1:9205 SW BARNES RD
Practice Address - Street 2:SUITE 20
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:503-216-2229
Practice Address - Fax:503-216-4041
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROV ST. VINCENT MEDICAL CTR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-30
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR063768Medicaid