NPIMap

Organization Active NPI

Providence Health & Services Oregon

Doing business as Providence Medical Group South

  • Family Medicine Physician
  • Medford, OR
National Provider Identifier
1568547503
Registry record updated Nov 19, 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 South
Practice address
965 Ellendale Dr
Medford, OR 97504-8215
Phone
(541) 732-6000
Fax
(541) 732-6005
NPI assigned
Oct 26, 2006
Last updated
Nov 19, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
PROVIDENCE HEALTH & SERVICES OREGONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 19, 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 6

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X NU
Adolescent and Children Mental Health Clinic/Center 261QM0855X NU
Family Medicine Physician 207Q00000X NU Primary
Internal Medicine Physician 207R00000X NU
Child & Adolescent Psychiatry Physician 2084P0804X NU
Geriatric Psychiatry Physician 2084P0805X NU

Addresses

Primary practice location

965 Ellendale Dr
Medford, OR 97504-8215

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
288515MedicaidOR
CG6801OtherORRAILROAD MEDICARE

Other names 1

  • PROVIDENCE MEDICAL GROUP SOUTH Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040310000315 OR Part B Supplier - Clinic/Group Practice 5294623245 Receives reassigned benefits from 200 practitioners
25 other NPIs on this enrollment
Practice locations: Central Point, OR; Medford, OR; Grants Pass, OR; Eagle Point, OR

Other NPIs on the same Medicare enrollment 25

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 25

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
38D2142115Providence Medical Group South Doctors965 Ellendale Dr, Medford, OR 97504Certificate of waiverJan 2, 2028

National Provider Directory

National Provider Directory
Part of
Providence Health Service-

Practitioners & affiliated clinicians

Practitioners 231

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 231

NPI Registry JSON

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

{
    "created_epoch": "1161820800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1763510400000",
    "number": "1568547503",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "965 ELLENDALE DR",
            "city": "MEDFORD",
            "state": "OR",
            "postal_code": "975048215",
            "telephone_number": "541-732-6000",
            "fax_number": "541-732-6005"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES OREGON",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HEALTH & SERVICES  OREGON",
        "enumeration_date": "2006-10-26",
        "last_updated": "2025-11-19",
        "certification_date": "2025-11-19",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "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
        },
        {
            "code": "2084P0804X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0805X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Geriatric Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "288515",
            "state": "OR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CG6801",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP SOUTH",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Medford, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 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.