Provider Demographics
NPI:1457625501
Name:PROVIDENCE HEALTH & SERVICE - OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICE - OREGON
Other - Org Name:PROVIDENCE HEART CLINIC CARDIOVASCULAR SURGERY EAST
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:
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 511
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2984
Practice Address - Country:US
Practice Address - Phone:503-962-1020
Practice Address - Fax:503-962-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500643323Medicaid
OR500643323Medicaid