NPIMap

Organization Active NPI

Providence Health & Services - Oregon

Doing business as Providence Medical Group

  • Family Medicine Physician
  • Gresham, OR
National Provider Identifier
1053419218
Registry record updated Jun 20, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
PROVIDENCE HEALTH & SERVICES - OREGON
Doing business as
Providence Medical Group
Practice address
440 NW Division St
Gresham, OR 97030-5506
Phone
(503) 215-9500
Fax
(503) 215-9525
NPI assigned
Sep 20, 2006
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
Mr. Donald W Anderson Jr.
Title
Asst Sec Enroll
Phone
(425) 358-9786

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary
Endocrinology, Diabetes & Metabolism Physician 207RE0101X NU
Clinic/Center 261Q00000X NU

Addresses

Primary practice location

440 NW Division St
Gresham, OR 97030-5506

Mailing address

PO Box 31001 - 4180
Pasadena, CA 91110-4180
Phone (503) 215-6494

Other practice location 1

5211 NE Glisan St Bldg C
Portland, OR 97213-3052
Phone (503) 215-6601

Other identifiers 1

IdentifierTypeStateIssuer
287333MedicaidOR

Other names 1

  • PROVIDENCE MEDICAL GROUP Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

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

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 147

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 147

NPI Registry JSON

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

{
    "created_epoch": "1158710400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750377600000",
    "number": "1053419218",
    "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",
            "telephone_number": "503-215-6494",
            "fax_number": "503-215-6644"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "440 NW DIVISION ST",
            "city": "GRESHAM",
            "state": "OR",
            "postal_code": "970305506",
            "telephone_number": "503-215-9500",
            "fax_number": "503-215-9525"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5211 NE Glisan St Bldg C",
            "address_purpose": "LOCATION",
            "city": "Portland",
            "state": "OR",
            "postal_code": "972133052",
            "country_code": "US",
            "telephone_number": "503-215-6601",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-20",
        "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": "W",
        "authorized_official_title_or_position": "ASST SEC ENROLL",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207RE0101X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Endocrinology, Diabetes & Metabolism",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "287333",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Gresham, 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.