Basic Information
| Provider Information | |||||||||
| NPI: | 1659451086 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH & SERVICES - OREGON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE PEDIATRIC SPECIALTIES III | ||||||||
| 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: | 1321 NE 99TH AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972209436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032168654 | ||||||||
| FaxNumber: | 5032168658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 04/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | NEYHART | ||||||||
| AuthorizedOfficialFirstName: | MITCHELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5035749840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HEALTH & SERVICES - OREGON | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | 269957 | 05 | OR | MEDICAID |