NPIMap

Organization Active NPI

Providence Health & Services Oregon

Doing business as Providence Medical Group

  • Adult Mental Health Clinic/Center
  • Portland, OR
National Provider Identifier
1093963209
Registry record updated May 26, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Adult Mental Health Clinic/CenterTaxonomy code 261QM0850X
Legal business name
PROVIDENCE HEALTH & SERVICES OREGON
Doing business as
Providence Medical Group
Providence Psychiatry East
Practice address
5251 NE Glisan St
BLDG a, 2ND Floor
Portland, OR 97213-3052
Phone
(503) 215-4860
NPI assigned
Aug 29, 2008
Last updated
May 26, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 26, 2026

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

Authorized official

Name
Donald W Anderson Jr.
Title
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Adult Mental Health Clinic/Center 261QM0850X NU Primary
Adolescent and Children Mental Health Clinic/Center 261QM0855X OR
Psychiatric/Mental Health Nurse Practitioner 363LP0808X OR
Psychiatry Physician 2084P0800X OR
Child & Adolescent Psychiatry Physician 2084P0804X OR
Geriatric Psychiatry Physician 2084P0805X OR

Addresses

Primary practice location

5251 NE Glisan St
BLDG a, 2ND Floor
Portland, OR 97213-3052

Mailing address

PO Box 31001 - 4180
Pasadena, CA 91110-4180

Other identifiers 2

IdentifierTypeStateIssuer
500601335MedicaidOR
500611962MedicaidOR

Other names 2

  • PROVIDENCE MEDICAL GROUP Doing business as
  • PROVIDENCE PSYCHIATRY EAST 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
Tax ID family
Sop Medical Group45 organizations share this tax ID, including this one

Other organizations with this tax ID 44

Organizations that report the same tax identification number in the National Provider Directory.

View all 44

Locations

5251 NE Glisan St
Bldg A
Portland, OR 97213
Phone (503) 215-2343

Practitioners & affiliated clinicians

Practitioners 21

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 21

NPI Registry JSON

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

{
    "created_epoch": "1219968000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1779753600000",
    "number": "1093963209",
    "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": "5251 NE GLISAN ST",
            "address_2": "BLDG A, 2ND FLOOR",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972133052",
            "telephone_number": "503-215-4860"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-08-29",
        "last_updated": "2026-05-26",
        "certification_date": "2026-05-26",
        "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_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": "OR",
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "OR",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "OR",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0804X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
            "state": "OR",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0805X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Geriatric Psychiatry",
            "state": "OR",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500601335",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500611962",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PROVIDENCE PSYCHIATRY EAST",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Portland, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 26, 2026; 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.