Provider Demographics
NPI:1326294117
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:PROVIDENCE MEDICAL GROUP MILL PLAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST CORP SECRETARY FOR ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
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 1:315 SE STONE MILL DR
Practice Address - Street 2:SUITE 102
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6987
Practice Address - Country:US
Practice Address - Phone:360-816-2700
Practice Address - Fax:360-816-2710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8873804Medicare PIN