Provider Demographics
NPI:1558693291
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:PROVIDENCE INFUSION AND HOME MEDICAL EQUIPMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST SEC FOR ENROLL/DIR REIMB ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 5936 B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-5936
Mailing Address - Country:US
Mailing Address - Phone:503-215-4663
Mailing Address - Fax:503-215-4655
Practice Address - Street 1:840 ROYAL AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6461
Practice Address - Country:US
Practice Address - Phone:541-732-5566
Practice Address - Fax:541-732-5503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0435600024Medicare NSC