Organization
PROVIDENCE HEALTH & SERVICES OREGON
Active
Other names
PMG BRIDGEPORT IMMEDIATE CARE, PROVIDENCE MEDICAL GROUP
Organization subpart
No
Provider details
NPI number
Authorized official
DONALD WAYNE ANDERSON JR. (ASST SECRETARY FOR ENROLLMENTS)
(425) 358-9786
Entity
Organization
Contact information
Practice address
18040 SW LOWER BOONES FERRY RD, SUITE 100, TIGARD, OR 97224
(503) 216-0700
Mailing address
PO BOX 3158, PORTLAND, OR 97208-3158
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
261Q00000X
Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500611230
—
OR
Enumeration date
06/03/2009
Last updated
07/04/2025
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