Basic Information
| Provider Information | |||||||||
| NPI: | 1578014239 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES OREGON | ||||||||
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| OtherOrganizationName: | PROVIDENCE MILWAUKIE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3397 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083397 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10150 SE 32ND AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972226516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035138300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2016 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REIMBURSEMENT ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 207ZC0006X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology |
No ID Information.