Basic Information
| Provider Information | |||||||||
| NPI: | 1225378615 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH & SERVICES - OREGON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE ST VINCENT HEART CLINIC HEART RHYTHM AT NEWBERG | ||||||||
| 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: | 1003 PROVIDENCE DR | ||||||||
| Address2: | SUITE 325 | ||||||||
| City: | NEWBERG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971327521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032160770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2013 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
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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 | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 500655723 | 05 | OR | MEDICAID |