Provider Demographics
NPI:1750459327
Name:PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - OREGON
Other - Org Name:PMG NEWBERG FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:NEYHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-574-9840
Mailing Address - Street 1:PO BOX 4949
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:308 VILLA RD
Practice Address - Street 2:SUITE 114
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-1881
Practice Address - Country:US
Practice Address - Phone:503-537-1850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES - OREGON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-01
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022847Medicaid
OR130132Medicare ID - Type UnspecifiedGROUP NUMBER