NPIMap

Organization Active NPI

Providence Health & Services - Oregon

Doing business as Providence Medical Group

  • Family Medicine Physician
  • Battle Ground, WA
National Provider Identifier
1194013144
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 Battle Ground Family Medicine
Practice address
101 NW 12TH Ave
Suite 107
Battle Ground, WA 98604-9141
Phone
(360) 666-4480
Fax
(360) 666-4485
NPI assigned
Jul 12, 2011
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
Physician Assistant 363A00000X NU
Family Medicine Physician 207Q00000X NU Primary
Internal Medicine Physician 207R00000X NU

Addresses

Primary practice location

101 NW 12TH Ave
Suite 107
Battle Ground, WA 98604-9141

Mailing address

PO Box 31001-4180
Pasadena, CA 91110-4180

Other practice location 1

3101 SE 192nd Ave Ste 103
Vancouver, WA 98683-1443
Phone (360) 666-4480

Other identifiers 1

IdentifierTypeStateIssuer
500639583MedicaidOR

Other names 2

  • PROVIDENCE MEDICAL GROUP Doing business as
  • Providence Medical Group Battle Ground Family Medicine Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
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

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

5228 NE Hoyt St
Ste B
Portland, OR 97213

Practitioners & affiliated clinicians

Practitioners 4

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": "1310428800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750377600000",
    "number": "1194013144",
    "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": "101 NW 12TH AVE",
            "address_2": "SUITE 107",
            "city": "BATTLE GROUND",
            "state": "WA",
            "postal_code": "986049141",
            "telephone_number": "360-666-4480",
            "fax_number": "360-666-4485"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3101 SE 192nd Ave Ste 103",
            "address_purpose": "LOCATION",
            "city": "Vancouver",
            "state": "WA",
            "postal_code": "986831443",
            "country_code": "US",
            "telephone_number": "360-666-4480",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-07-12",
        "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": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500639583",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Medical Group Battle Ground Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Battle Ground, 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.