1366536963 NPI number — PROVIDENCE HEALTH & SERVICES OREGON

Table of content: (NPI 1366536963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366536963 NPI number — PROVIDENCE HEALTH & SERVICES OREGON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH & SERVICES OREGON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROVIDENCE MILWAUKIE HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366536963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3397
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-215-4323
Provider Business Mailing Address Fax Number:
503-215-0297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10150 SE 32ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKIE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97222-6516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-652-8300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
W
Authorized Official Title or Position:
ASST SEC FOR ENROLL/DIR REIMB ADMIN
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 138008200 . This is a "REGENCE HOSPITAL NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 175620 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 194589600 . This is a "US DEPT. OF LABOR WC" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 050100000001 . This is a "PROVIDENCE HEALTH PLAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 3003373 . This is a "WASHINGTON MEDICAID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: C45062 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 95916 . This is a "WA DEPT. OF LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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