Provider Demographics
NPI:1487746491
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY OF ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-358-9786
Mailing Address - Street 1:4400 NE HALSEY ST
Mailing Address - Street 2:BUILDING 1, STE 129
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1545
Mailing Address - Country:US
Mailing Address - Phone:503-215-4601
Mailing Address - Fax:503-215-4624
Practice Address - Street 1:2033 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9744
Practice Address - Country:US
Practice Address - Phone:541-732-6500
Practice Address - Fax:541-732-6504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13-140734251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR019773Medicaid
OR303804000001OtherPROVIDENCE HEALTH PLAN
OR026699000OtherBLUE CROSS
OR930386912-05OtherODS
OR026699000OtherBLUE CROSS
OR930386912-05OtherODS