NPIMap

Organization Active NPI

Providence Health & Services Oregon

Doing business as Prov Peds Neurology Longview

  • Pediatrics Physician
  • Longview, WA
National Provider Identifier
1104097906
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
Doing business as
Prov Peds Neurology Longview
Providence Medical Group
Practice address
971 11TH Ave
Longview, WA 98632-2503
Phone
(360) 577-1771
NPI assigned
Mar 19, 2008
Last updated
Jun 20, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
PROVIDENCE HEALTH & SERVICES - OREGONAs reported in NPPES

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
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X Primary
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 2

  • PROV PEDS NEUROLOGY LONGVIEW Doing business as
  • 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
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

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
Part of
Providence Health Service-

Practitioners & affiliated clinicians

Practitioners 79

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 79

NPI Registry JSON

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

{
    "created_epoch": "1205884800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750377600000",
    "number": "1104097906",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "971 11TH AVE",
            "city": "LONGVIEW",
            "state": "WA",
            "postal_code": "986322503",
            "telephone_number": "360-577-1771"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES OREGON",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "enumeration_date": "2008-03-19",
        "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": "ASSISTANT SECRETARY OF ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-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": "PROV PEDS NEUROLOGY LONGVIEW",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Longview, WA

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.