Provider Demographics
NPI:1205924313
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-358-9786
Mailing Address - Street 1:4400 NE HALSEY STREET
Mailing Address - Street 2:BUILDING 1 SUITE 129
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1545
Mailing Address - Country:US
Mailing Address - Phone:503-215-2273
Mailing Address - Fax:503-215-8274
Practice Address - Street 1:6410 NE HALSEY ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4742
Practice Address - Country:US
Practice Address - Phone:503-215-2273
Practice Address - Fax:503-215-8274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241350Medicaid
OR381500Medicare PIN