Provider Demographics
NPI:1558430314
Name:PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - OREGON
Other - Org Name:PMG SOUTH DIABETES EDUCATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-732-6000
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:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:1698 E MCANDREWS RD
Practice Address - Street 2:SUITE 170
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5589
Practice Address - Country:US
Practice Address - Phone:541-732-6957
Practice Address - Fax:541-732-7901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES - OREGON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-07
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500616621OtherDMAP
ORCG6801OtherRAIL ROAD MEDICARE
OR500616621OtherDMAP