NPIMap

Organization Active NPI

Providence Health & Services Oregon

Doing business as Providence Medical Group

  • Internal Medicine Physician
  • Portland, OR
National Provider Identifier
1164623401
Registry record updated Jun 20, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
PROVIDENCE HEALTH & SERVICES OREGON
Doing business as
Providence Medical Group
Practice address
4400 NE Halsey St
Portland, OR 97213-1545
Phone
(503) 893-6524
NPI assigned
May 31, 2007
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 Wayne Anderson Jr.
Title
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 104100000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X Primary
Clinic/Center 261Q00000X

Addresses

Primary practice location

4400 NE Halsey St
Portland, OR 97213-1545

Mailing address

PO Box 31001 - 4180
Pasadena, CA 91110-4180

Other names 1

  • Providence Medical Group Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR, WA, CO, AK, CA, MI, MT, FL, NV, MO, DC, TX, NY, HI, ID, AZ, MN, IL, WI, NE, UT, NC, NJ, TN24 enrollments

Enrollment records 24

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
This NPI is an additional NPI on the enrollment
O20181217001928 CO Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Frisco, CO
O20190131000428 AK Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 5 practitioners
Practice locations: Anchorage, AK
O20190208002324 CA Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 15 practitioners
Practice locations: Walnut Creek, CA; Truckee, CA; San Francisco, CA; San Diego, CA; Glendale, CA; Riverside, CA; Redlands, CA; Los Angeles, CA…
O20190814001020 MI Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 4 practitioners
Practice locations: Saint Clair Shores, MI; Shelby, MI; Hudsonville, MI; Hart, MI; Ada, MI; Ludington, MI
O20200327001992 MT Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 7 practitioners
Practice locations: Missoula, MT; Lolo, MT
O20200825000088 FL Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Miami, FL
O20200826002266 NV Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 4 practitioners
Practice locations: Reno, NV
O20201023002706 MO Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Manchester, MO
O20210519002348 DC Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Bowie, MD
O20210920001288 TX Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 6 practitioners
Practice locations: Westlake, TX; Irving, TX; Houston, TX; Frisco, TX; Friendswood, TX
O20211105002351 NY Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 3 practitioners
Practice locations: Brooklyn, NY; White Plains, NY; Syosset, NY
O20211109000906 HI Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Honolulu, HI
O20220516000248 ID Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 2 practitioners
Practice locations: Boise, ID; Kuna, ID
O20230215002913 AZ Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Green Valley, AZ
O20230809001911 MN Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Minneapolis, MN
O20240802003387 IL Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 3 practitioners
Practice locations: Oak Brook, IL; Oak Park, IL; Park Ridge, IL
O20241008004406 WI Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Williams Bay, WI
O20241015000805 NE Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Elkhorn, NE
O20250429002938 UT Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 2 practitioners
Practice locations: St George, UT; Hurricane, UT
O20250630000871 NC Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Huntersville, NC
O20251031000928 NJ Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Hillside, NJ
O20251031002865 TN Part B Supplier - Clinic/Group Practice 0648183608 Receives reassigned benefits from 1 practitioner
Practice locations: Memphis, TN

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

Locations

4400 NE Halsey St
Portland, OR 97213
Phone (503) 215-6556

550 17th Ave
#4W
Seattle, WA 98122
Phone (206) 320-3494

Practitioners & affiliated clinicians

Practitioners 125

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 125

NPI Registry JSON

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

{
    "created_epoch": "1180569600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750377600000",
    "number": "1164623401",
    "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": "4400 NE HALSEY ST",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972131545",
            "telephone_number": "503-893-6524"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-31",
        "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": "104100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "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": "Providence Medical Group",
            "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 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.