NPIMap

Organization Active NPI

Providence Health & Services - Oregon

Doing business as Providence Medical Group

  • Neurology with Special Qualifications in Child Neurology Physician
  • Portland, OR
National Provider Identifier
1316125149
Registry record updated Jul 4, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Neurology with Special Qualifications in Child Neurology PhysicianTaxonomy code 2084N0402X
Legal business name
PROVIDENCE HEALTH & SERVICES - OREGON
Doing business as
Providence Medical Group
Providence Pediatric Neurology MJP
Practice address
9427 SW Barnes Rd Ste 395
Portland, OR 97225-6652
Phone
(503) 216-1280
Fax
(503) 216-1288
NPI assigned
Feb 4, 2008
Last updated
Jul 4, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 4, 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 Enrollment
Phone
(425) 358-9786

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X
Neurology with Special Qualifications in Child Neurology Physician 2084N0402X Primary

Addresses

Primary practice location

9427 SW Barnes Rd Ste 395
Portland, OR 97225-6652

Mailing address

PO Box 3158
Portland, OR 97208-3158

Other identifiers 1

IdentifierTypeStateIssuer
279056MedicaidOR

Other names 2

  • PROVIDENCE MEDICAL GROUP Doing business as
  • PROVIDENCE PEDIATRIC NEUROLOGY MJP 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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
38D2235633Providence Pediatric Neurology9427 SW Barnes Rd, Ste 395, Portland, OR 97225Certificate of waiverSep 9, 2027

National Provider Directory

National Provider Directory
Tax ID family
Sop Medical Group45 organizations share this tax ID, including this one

Other organizations with this tax ID 44

Organizations that report the same tax identification number in the National Provider Directory.

View all 44

Locations

9427 SW Barnes Rd
Ste 395
Portland, OR 97225
Phone (503) 216-2602

Practitioners & affiliated clinicians

Practitioners 18

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 18

NPI Registry JSON

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

{
    "created_epoch": "1202083200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751587200000",
    "number": "1316125149",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3158",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083158"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9427 SW BARNES RD STE 395",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972256652",
            "telephone_number": "503-216-1280",
            "fax_number": "503-216-1288"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-02-04",
        "last_updated": "2025-07-04",
        "certification_date": "2025-07-04",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY ENROLLMENT",
        "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": "2084N0402X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology with Special Qualifications in Child Neurology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "279056",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PROVIDENCE PEDIATRIC NEUROLOGY MJP",
            "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 Jul 4, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.