Provider Demographics
NPI:1689755670
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:PROVIDENCE MEDFORD MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST SEC FOR ENROLL/DIR REIMB ADMIN
Authorized Official - Prefix:MR
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 3308
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3308
Mailing Address - Country:US
Mailing Address - Phone:503-215-4323
Mailing Address - Fax:503-215-0297
Practice Address - Street 1:1111 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6241
Practice Address - Country:US
Practice Address - Phone:503-215-4323
Practice Address - Fax:503-215-0297
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES OREGON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-18
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR24861OtherWA DEPT OF LABOR
ORC45121OtherRAILROAD MEDICARE
OR3030202OtherWASHINGTON MEDICAID
ORR0000ZGBJCOtherMEDICARE PART B
OR194077900OtherUS DEPT OF LABOR WC
OR330046000001OtherPROVIDENCE HEALTH PLAN
ORC45121OtherRAILROAD MEDICARE
ORR0000ZGBJCOtherMEDICARE PART B
OR194077900OtherUS DEPT OF LABOR WC
OR3030202OtherWASHINGTON MEDICAID