Provider Demographics
NPI:1245567817
Name:PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - OREGON
Other - Org Name:PROVIDENCE MEDICAL GROUP CANBY IMMEDIATE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST SEC FOR ENROLLMENT/DIR REIMB S
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
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 1:200 S HAZEL DELL WAY
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-7829
Practice Address - Country:US
Practice Address - Phone:503-263-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500617241Medicaid
ORR0000WCRBFMedicare PIN