1912282369 NPI number — PROVIDENCE HEALTH & SERVICES - OREGON

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912282369 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 WILLAMETTE FALLS MEDICAL CENTER
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:
1912282369
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3456
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:
97208-3456
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:
1500 DIVISION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-215-2364
Provider Business Practice Location Address Fax Number:
503-215-2345
Provider Enumeration Date:
10/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
ASST CORP SECRETARY FOR ENROLLMENTS
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: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 140563 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 93940 . This is a "WA DOLI PROV NUM 1500;S" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1380038 . This is a "BLUE CROSS PROVIDER NUM" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: P042001 . This is a "PACIFIC SOURCE PROV NUM" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 3012408 . This is a "MEDICAID - WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 217653 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25725 . This is a "WA DOLI PROV NUM UB04'S" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0414531 . This is a "TRIWEST PROVIDER NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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