Basic Information
| Provider Information | |||||||||
| NPI: | 1194057497 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES - OREGON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE MEDICAL GROUP OREGON CITY SPINE CENTER | ||||||||
| 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: | 1510 DIVISION ST | ||||||||
| Address2: | STE 170 | ||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970451581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036506288 | ||||||||
| FaxNumber: | 5036506884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2010 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | FREEMAN | ||||||||
| AuthorizedOfficialFirstName: | KEENAN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5038936524 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 500620086 | 05 | OR | MEDICAID |