Organization
PROVIDENCE HEALTH & SERVICES - OREGON
Active
Other names
PROVIDENCE MEDICAL GROUP, PROVIDENCE MEDICAL GROUP DERMATOLOGIC SPECIALTIES
Organization subpart
No
Provider details
NPI number
Authorized official
DONALD WAYNE ANDERSON JR. (ASSISTANT SECRETARY ENROLLMENT)
(425) 358-9786
Entity
Organization
Contact information
Practice address
5330 NE GLISAN ST, SUITE 200, PORTLAND, OR 97213-3069
(503) 215-9080
Mailing address
PO BOX 31001 - 4180, PASADENA, CA 91110-4180
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
207ND0101X
MOHS-Micrographic Surgery Physician
—
—
207NS0135X
Procedural Dermatology Physician
—
—
261Q00000X
Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
006508
—
OR
Enumeration date
06/27/2007
Last updated
07/04/2025
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