NPIMap

Organization Active NPI

Providence Health & Services - Oregon

Doing business as Providence Medical Group

  • Family Medicine Physician
  • Portland, OR
National Provider Identifier
1124129903
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
Providence Medical Group Gateway Family & Community Medicine
Practice address
1321 NE 99TH Ave
Suite 200
Portland, OR 97220-9439
Phone
(503) 215-4250
Fax
(503) 215-4255
NPI assigned
Sep 26, 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
Donald W Anderson Jr.
Title
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

1321 NE 99TH Ave
Suite 200
Portland, OR 97220-9439

Mailing address

PO Box 31001 - 4180
Pasadena, CA 91110-4180
Phone (503) 215-6446

Other identifiers 1

IdentifierTypeStateIssuer
022844MedicaidOR

Other names 2

  • PROVIDENCE MEDICAL GROUP Doing business as
  • Providence Medical Group Gateway Family & Community Medicine 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

Locations

310 N Villa Rd
Ste 101
Newberg, OR 97132
Phone (503) 537-3546

10330 SE 32nd Ave
Ste 205
Portland, OR 97222
Phone (503) 513-8950

5050 NE Hoyt St
Ste 615
Portland, OR 97213
Phone (503) 215-8580

9427 SW Barnes Rd
Ste 495
Portland, OR 97225
Phone (503) 216-0900

3101 SE 192nd Ave
Ste 103
Vancouver, WA 98683
Phone (360) 666-4480

Practitioners & affiliated clinicians

Practitioners 20

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 20

NPI Registry JSON

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

{
    "created_epoch": "1159228800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750377600000",
    "number": "1124129903",
    "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": "503-215-6446",
            "fax_number": "503-215-6644"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1321 NE 99TH AVE",
            "address_2": "SUITE 200",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972209439",
            "telephone_number": "503-215-4250",
            "fax_number": "503-215-4255"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-26",
        "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_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "022844",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Medical Group Gateway Family & Community Medicine",
            "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 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.