Basic Information
| Provider Information | |||||||||
| NPI: | 1093135535 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH & SERVICES - OREGON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE MEDICAL GROUP SCHOLLS PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12442 SW SCHOLLS FERRY RD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972230804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032169140 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2014 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | DIR REIMB REG STRAT/ASST SEC ENROLL | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.