Provider Demographics
NPI:1891992624
Name:PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - OREGON
Other - Org Name:PROVIDENCE MEDICAL GROUP DERMATOLOGIC SPECIALTIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEENAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-893-6524
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5330 NE GLISAN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3069
Practice Address - Country:US
Practice Address - Phone:503-215-9080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006508Medicaid
OR006508Medicaid