Basic Information
| Provider Information | |||||||||
| NPI: | 1053403394 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES OREGON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ONE MEDICAL WITH PROVIDENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032156494 | ||||||||
| FaxNumber: | 5032156644 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 NE HALSEY ST | ||||||||
| Address2: | BLDG 2, FL 3 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038937120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 10/22/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST SEC FOR ENROLLMENT/DIR REIMB S | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.