NPIMap

Organization Active NPI

Providence Health & Services - Oregon

  • Pediatrics Physician
  • Tigard, OR
National Provider Identifier
1093135535
Registry record updated Jun 20, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
PROVIDENCE HEALTH & SERVICES - OREGON
Practice address
12442 SW Scholls Ferry Rd
Suite 205
Tigard, OR 97223-0804
Phone
(503) 216-9140
NPI assigned
Apr 23, 2014
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
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X Primary
Clinic/Center 261Q00000X

Addresses

Primary practice location

12442 SW Scholls Ferry Rd
Suite 205
Tigard, OR 97223-0804

Mailing address

PO Box 31001-4180
Pasadena, CA 91110-4180

Other names 2

  • PROVIDENCE MEDICAL GROUP Doing business as
  • Providence Medical Group Scholls Pediatrics 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 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1398211200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750377600000",
    "number": "1093135535",
    "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": "12442 SW SCHOLLS FERRY RD",
            "address_2": "SUITE 205",
            "city": "TIGARD",
            "state": "OR",
            "postal_code": "972230804",
            "telephone_number": "503-216-9140"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-04-23",
        "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": "ASSISTANT SECRETARY OF ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Medical Group Scholls Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tigard, 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.