Organization
PROVIDENCE HEALTH & SERVICES - OREGON
Active
Other names
PROVIDENCE MEDICAL GROUP, Providence Medical Group Sports Care
Organization subpart
No
Provider details
NPI number
Authorized official
DONALD WAYNE ANDERSON JR. (ASSISTANT SECREATRY FOR ENROLLMENT)
(425) 358-9786
Entity
Organization
Contact information
Practice address
909 SW 18TH AVE, PORTLAND, OR 97205-1705
(503) 962-1946
(503) 962-1925
Mailing address
PO BOX 31001 - 4180, PASADENA, CA 91110-4180
(503) 215-6494
(503) 215-6644
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
—
—
207RS0010X
Sports Medicine (Internal Medicine) Physician
Primary
—
—
261Q00000X
Clinic/Center
—
—
Other
Enumeration date
02/21/2013
Last updated
07/04/2025
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