Provider Demographics
NPI:1891861605
Name:PROVIDENCE PORTLAND MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENCE PORTLAND MEDICAL CENTER
Other - Org Name:PROVIDENCE ARTHRITIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-215-6241
Mailing Address - Street 1:PO BOX 3395
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 155
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-215-6819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PORTLAND MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-27
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210638Medicaid
OR0000ZBBVWMedicare PIN