Provider Demographics
NPI:1629720479
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST SECRETARY FOR ENROLLMENT
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 3396
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3396
Mailing Address - Country:US
Mailing Address - Phone:503-215-1234
Mailing Address - Fax:
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:503-215-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant SurgeryGroup - Single Specialty