1831289826 NPI number — PROVIDENCE HEALTH & SERVICES OREGON

Table of content: (NPI 1831289826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831289826 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:
1831289826
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5936A
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:
97228-5936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-215-4663
Provider Business Mailing Address Fax Number:
503-215-4655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6410 NE HALSEY ST
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97213-4742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-215-4663
Provider Business Practice Location Address Fax Number:
503-215-4655
Provider Enumeration Date:
10/13/2006

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: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BX2000X , with the licence number: NPC-0002697 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 108837 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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