Provider Demographics
NPI:1649344458
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:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-358-9786
Mailing Address - Street 1:PO BOX 31001-4199
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-4199
Mailing Address - Country:US
Mailing Address - Phone:503-215-4323
Mailing Address - Fax:503-215-0297
Practice Address - Street 1:727 S WAHANNA RD
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138
Practice Address - Country:US
Practice Address - Phone:503-717-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE SEASIDE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-20
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR039607OtherMEDICAID CLINIC - 1500 BILLING
OR000138Medicaid
OR7042567OtherWASHINGTON MEDICAID
ORC13774OtherRAILROAD MEDICARE
OR015560000OtherREGENCE BCBSO CLINIC #
OR383981Medicare ID - Type UnspecifiedMEDICARE RHC NUMBER
OR0000WCNGPMedicare ID - Type UnspecifiedPART B MEDICARE NO