Basic Information
| Provider Information | |||||||||
| NPI: | 1235479643 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES - OREGON | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROVIDENCE MEDICAL GROUP SPORTS CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 909 SW 18TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972051705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039621946 | ||||||||
| FaxNumber: | 5039621925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2013 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST SEC FOR ENROLLMENT/DIR REIMB | ||||||||
| AuthorizedOfficialTelephone: | 4252763215 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.