Basic Information
| Provider Information | |||||||||
| NPI: | 1417978008 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY EMANUEL HOSPITAL & HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4399 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 N COLUMBIA RIVER HWY STE 2 | ||||||||
| Address2: | |||||||||
| City: | SAINT HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970511201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033977119 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 01/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM CFO | ||||||||
| AuthorizedOfficialTelephone: | 5034155145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEGACY EMANUEL HOSPITAL & HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 14-0056 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7711865 | 05 | WA | MEDICAID | 092597 | 05 | OR | MEDICAID |