NPIMap

Organization Active NPI

Providence Health & Services Oregon

Doing business as Providence Medical Group

  • General Practice Physician
  • Lake Oswego, OR
National Provider Identifier
1023488343
Registry record updated Jun 20, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
Legal business name
PROVIDENCE HEALTH & SERVICES OREGON
Doing business as
Providence Medical Group
Practice address
4823 Meadows Rd
Lake Oswego, OR 97035-2529
Phone
(503) 216-1580
NPI assigned
Sep 29, 2015
Last updated
Jun 20, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 20, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Donald Wayne Anderson Jr.
Title
Asst Secretary for Enrollment
Phone
(425) 525-5392

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X
General Practice Physician 208D00000X Primary

Addresses

Primary practice location

4823 Meadows Rd
Lake Oswego, OR 97035-2529

Mailing address

PO Box 31001 - 4180
Pasadena, CA 91110-4180

Other names 1

  • PROVIDENCE MEDICAL GROUP Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR, WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031106000652 OR Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1,658 practitioners
O20080630000201 WA Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 77 practitioners
15 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 14

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 14

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1,807

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 1,807

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1443484800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750377600000",
    "number": "1023488343",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 31001 - 4180",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911104180"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4823 MEADOWS RD",
            "city": "LAKE OSWEGO",
            "state": "OR",
            "postal_code": "970352529",
            "telephone_number": "503-216-1580"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-09-29",
        "last_updated": "2025-06-20",
        "certification_date": "2025-06-20",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "ASST SECRETARY FOR ENROLLMENT",
        "authorized_official_telephone_number": "425-525-5392",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake Oswego, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.