# PROVIDENCE HEALTH & SERVICES - OREGON

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** PROVIDENCE HEALTH & SERVICES - OREGON
- **Other names:** PMG SOUTH VASCULAR AND GENERAL SURGERY, PROVIDENCE MEDICAL GROUP SOUTH
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1750460283
- **Legal business name:** PROVIDENCE HEALTH & SERVICES - OREGON
- **Authorized official:** DONALD WAYNE ANDERSON JR. (ASSISTANT SECRETARY ENROLLMENT)
- **Authorized official phone:** (425) 358-9786

## Contact information

- **Practice address:** 940 ROYAL AVE, SUITE 420, MEDFORD, OR 97504-6193
- **Practice address phone:** (541) 732-8388
- **Practice address fax:** (541) 732-8387
- **Mailing address:** PO BOX 31001 - 4180, PASADENA, CA 91110-4180
- **Mailing address phone:** (503) 215-6494

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2086S0129X | Vascular Surgery Physician | — | NULL | Yes |
| 2086S0129X | Vascular Surgery Physician | — | — | Yes |
| 261Q00000X | Clinic/Center | — | NULL | — |

## Other

- **Enumeration date:** 11/03/2006
- **Last updated:** 11/19/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 213241 | — | OR |
| 01 | — | CG6801 | RAIL ROAD MEDICARE | OR |