Provider Demographics
NPI:1013944776
Name:PROVIDENCE MEDFORD MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENCE MEDFORD MEDICAL CENTER
Other - Org Name:PROVIDENCE MEDFORD MEDICAL CENTER LIFELINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:HANENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-732-5050
Mailing Address - Street 1:P.O. BOX 3308
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3308
Mailing Address - Country:US
Mailing Address - Phone:503-215-4050
Mailing Address - Fax:503-215-4343
Practice Address - Street 1:1111 CRATER LAKE AVENUE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6214
Practice Address - Country:US
Practice Address - Phone:541-732-5000
Practice Address - Fax:541-732-5131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QE0002X
OR140734282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227950Medicaid
OR087ZGBJCMedicare ID - Type UnspecifiedIMMUNIZATION BILLER