1093894511 NPI number — PROVIDENCE HEALTH & SERVICES OREGON

Table of content: (NPI 1093894511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093894511 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:
Provider Other Organization Name Type Code:
6
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:
1093894511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3158
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:
97208-3158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-215-6494
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1698 E MCANDREWS RD
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-5589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-732-7874
Provider Business Practice Location Address Fax Number:
541-732-7875
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
541-732-6000

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 022869 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: CG6801 . This is a "RAIL ROAD MEDIARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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