NPIMap

Organization Active NPI

Providence Health & Services - Oregon

  • Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
  • Portland, OR
National Provider Identifier
1396019451
Registry record updated Jun 30, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianTaxonomy code 208G00000X
Legal business name
PROVIDENCE HEALTH & SERVICES - OREGON
Practice address
4805 NE Glisan St
Ste 6N50
Portland, OR 97213-2933
Phone
(503) 215-2300
NPI assigned
Mar 6, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 30, 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
Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208G00000X Primary
Clinic/Center 261Q00000X

Addresses

Primary practice location

4805 NE Glisan St
Ste 6N50
Portland, OR 97213-2933

Mailing address

PO Box 31001 - 4180
Pasadena, CA 91110-4180

Other identifiers 1

IdentifierTypeStateIssuer
500644062MedicaidOR

Other names 2

  • PROVIDENCE MEDICAL GROUP Doing business as
  • Providence Thoracic Surgery 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

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1330992000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751241600000",
    "number": "1396019451",
    "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": "4805 NE GLISAN ST",
            "address_2": "STE 6N50",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972132933",
            "telephone_number": "503-215-2300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-03-06",
        "last_updated": "2025-06-30",
        "certification_date": "2025-06-30",
        "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": "208G00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500644062",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Thoracic Surgery",
            "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 30, 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.