Providence Health & Services Oregon
Organization Active NPI Pediatrics Physician · Longview, WA
NPI 1104097906 · NPPES record last updated Jun 20, 2025
Key facts
- NPI
- 1104097906
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pediatrics Physician 208000000X
- Legal business name
- PROVIDENCE HEALTH & SERVICES OREGON
- Practice address
- 971 11TH Ave
Longview, WA 98632-2503 - Phone
- (360) 577-1771
- NPI assigned
- Mar 19, 2008
- Organization subpart
- Yes
- Parent organization (as reported)
- PROVIDENCE HEALTH & SERVICES - OREGON
Authorized official
- Name
- Donald Wayne Anderson Jr.
- Title
- Assistant Secretary of Enrollments
- Phone
- (425) 358-9786
Other NPIs on the same Medicare enrollment 14
Other NPIs with the same Medicare PAC ID 3
Practitioners 1,434
-
Benjamin Edward Atkinson, M.D.
-
Michael Meng Chen, MD, MS
-
Damanjeet Singh Chugh, M.D.
-
Ruxandra M Costa, MD
-
Hisam Said Goueli, M.D.
-
Joshua CW Jones, M.D.
-
James William Jordan, M.D.
-
Kitti Kaiboriboon, M.D.
-
Pin-Yi Ko, MD
-
George A Lopez, MD
-
William Lou, MD
-
Yi Mao, MBBS
-
Ravi Sivasankara Menon, M.D.
-
Lien B Nguyen, DO
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in OR, WA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
| O20080630000201 | WA | Part B Supplier - Clinic/Group Practice | 0648183608 |
Receives reassigned benefits from 77 practitioners 15 other NPIs on this enrollment |
National Provider Directory
- Part of
- Scholls Medical Group
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician |
208000000X | Yes | ||
| Clinic/Center | 261Q00000X |
Addresses
Primary practice location
971 11TH Ave
Longview, WA 98632-2503
Mailing address
PO Box 31001 - 4180
Pasadena, CA 91110-4180
Phone (503) 215-6494
Other names
- PROV PEDS NEUROLOGY LONGVIEW
- PROVIDENCE MEDICAL GROUP
Other providers in Longview, WA
- Evan Walker Prewitt
- Athena Priddy
- Jessica Pritchett
- Sarah Kay Probasco
- Progress Center,Inc
- Brittany Paige Pruitt
- Sarah Pryor
- Alena Prystupa
- PT Northwest of Longview Inc
- Kelly Ann Purcell
All providers in Longview, WA · Pediatrics Physician in Washington
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 20, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.