Provider Demographics
NPI:1831289826
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:PROVIDENCE 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 5936A
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 1:6410 NE HALSEY ST
Practice Address - Street 2:SUITE 500
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4742
Practice Address - Country:US
Practice Address - Phone:503-215-4663
Practice Address - Fax:503-215-4655
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES - OREGON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-13
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
ORNPC-0002697332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR108837Medicaid
OR108837Medicaid