Provider Demographics
NPI:1497187710
Name:PROVIDENCE HEALTH & SERVICES -OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES -OREGON
Other - Org Name:PROVIDENCE NEWBERG ONCOLOGY PALLIATIVE CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEENAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-593-6524
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 1:1003 PROVIDENCE DR
Practice Address - Street 2:SUITE 310
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7524
Practice Address - Country:US
Practice Address - Phone:503-537-6040
Practice Address - Fax:503-537-6045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-09
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500661531Medicaid
ORR130132Medicare PIN