NPIMap

Organization Active NPI

Providence Health & Services - Oregon

Doing business as Providence Dysplasia Clinic

  • Hematology & Oncology Physician
  • Portland, OR
National Provider Identifier
1124325972
Registry record updated Mar 23, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Hematology & Oncology PhysicianTaxonomy code 207RH0003X
Legal business name
PROVIDENCE HEALTH & SERVICES - OREGON
Doing business as
Providence Dysplasia Clinic
Providence Medical Group
Practice address
4805 NE Glisan St Ste 11N
Portland, OR 97213-2933
Phone
(503) 215-1600
Fax
(503) 215-1600
NPI assigned
Feb 14, 2011
Last updated
Mar 23, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 23, 2026

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
Clinic/Center 261Q00000X
Hematology & Oncology Physician 207RH0003X Primary

Addresses

Primary practice location

4805 NE Glisan St Ste 11N
Portland, OR 97213-2933

Mailing address

PO Box 31001 - 4180
Pasadena, CA 91110-4180
Phone (503) 215-6494

Other identifiers 1

IdentifierTypeStateIssuer
500632601MedicaidOR

Other names 2

  • PROVIDENCE DYSPLASIA CLINIC Doing business as
  • PROVIDENCE MEDICAL GROUP 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

9135 SW Barnes Rd
Ste 761
Portland, OR 97225
Phone (503) 216-2602

Practitioners & affiliated clinicians

Practitioners 7

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.

NPI Registry JSON

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

{
    "created_epoch": "1297641600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1774224000000",
    "number": "1124325972",
    "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",
            "fax_number": "503-215-6644"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4805 NE GLISAN ST STE 11N",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972132933",
            "telephone_number": "503-215-1600",
            "fax_number": "503-215-1600"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-02-14",
        "last_updated": "2026-03-23",
        "certification_date": "2026-03-23",
        "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": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RH0003X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Hematology & Oncology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500632601",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE DYSPLASIA CLINIC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "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 Mar 23, 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.