Organization
PROVIDENCE HEALTH & SERVICES - OREGON
Active
Parent organization
PROVIDENCE HEALTH & SERVICES - OREGON
Other names
PMG SOUTH MEDFORD PEDIATRICS, PROVIDENCE MEDICAL GROUP SOUTH
Organization subpart
Yes
Provider details
NPI number
Legal business name
PROVIDENCE HEALTH & SERVICES - OREGON
Authorized official
DONALD WAYNE ANDERSON JR. (ASSISTANT SECRETARY ENROLLMENT)
(425) 358-9786
Entity
Organization
Contact information
Practice address
840 ROYAL AVE, SUITE 110, MEDFORD, OR 97504-6461
(541) 732-8370
(541) 732-8371
Mailing address
PO BOX 31001 - 4180, PASADENA, CA 91110-4180
(503) 215-6494
Taxonomy
Speciality
Code
Description
License number
State
2084P0804X
Child & Adolescent Psychiatry Physician
Primary
—
—
261Q00000X
Clinic/Center
—
—
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CG6801
RAIL ROAD MEDICARE
OR
Enumeration date
11/01/2006
Last updated
11/19/2025
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