1649344458 NPI number — PROVIDENCE HEALTH & SERVICES OREGON

Table of content: (NPI 1649344458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649344458 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:
1649344458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2018
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:
727 S WAHANNA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEASIDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-717-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
ASST CORP SEC FOR ENROLLMENTS
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 039607 . This is a "MEDICAID CLINIC - 1500 BILLING" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: C13774 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 000138 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 015560000 . This is a "REGENCE BCBSO CLINIC #" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 7042567 . This is a "WASHINGTON MEDICAID" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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