Provider Demographics
NPI:1912282369
Name:PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - OREGON
Other - Org Name:PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST CORP SECRETARY FOR 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:425-525-5392
Mailing Address - Street 1:PO BOX 3456
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3456
Mailing Address - Country:US
Mailing Address - Phone:503-215-4323
Mailing Address - Fax:503-215-0297
Practice Address - Street 1:1500 DIVISION ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1527
Practice Address - Country:US
Practice Address - Phone:503-215-2364
Practice Address - Fax:503-215-2345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-18
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X, 207P00000X, 207R00000X, 207U00000X, 207V00000X, 207ZP0102X, 261QA1903X
OR140563282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA93940OtherWA DOLI PROV NUM 1500;S
OR1380038OtherBLUE CROSS PROVIDER NUM
ORP042001OtherPACIFIC SOURCE PROV NUM
WA3012408OtherMEDICAID - WA
OR217653Medicaid
WA25725OtherWA DOLI PROV NUM UB04'S
OR0414531OtherTRIWEST PROVIDER NUMBER
WA93940OtherWA DOLI PROV NUM 1500;S