Provider Demographics
NPI:1922481456
Name:PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - OREGON
Other - Org Name:PMG EAGLE POINT PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR REIMB REG STRAT/ASST SEC ENROLL
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 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:541-830-4060
Mailing Address - Fax:541-830-4090
Practice Address - Street 1:10830 HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:EAGLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97524-9516
Practice Address - Country:US
Practice Address - Phone:541-830-4060
Practice Address - Fax:541-830-4090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-01
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500688628Medicaid
R105969Medicare PIN