NPIMap

Organization Active NPI

Providence Health & Services - Oregon

Doing business as Providence Medical Group

  • Pediatric Surgery Physician
  • Portland, OR
National Provider Identifier
1659451086
Registry record updated Jul 4, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Surgery PhysicianTaxonomy code 2086S0120X
Legal business name
PROVIDENCE HEALTH & SERVICES - OREGON
Doing business as
Providence Medical Group
Providence Pediatric Specialties III
Practice address
1321 NE 99TH Ave
Suite 200
Portland, OR 97220-9436
Phone
(503) 216-8654
Fax
(503) 216-8658
NPI assigned
Oct 17, 2006
Last updated
Jul 4, 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 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 Secreatry for Enrollment
Phone
(425) 358-9786

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Surgery Physician 2086S0120X Primary

Addresses

Primary practice location

1321 NE 99TH Ave
Suite 200
Portland, OR 97220-9436

Mailing address

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

Other names 2

  • PROVIDENCE MEDICAL GROUP Doing business as
  • PROVIDENCE PEDIATRIC SPECIALTIES III Doing business as

National Provider Directory

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

Other organizations with this tax ID 44

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

View all 44

NPI Registry JSON

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

{
    "created_epoch": "1161043200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751587200000",
    "number": "1659451086",
    "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",
            "fax_number": "503-215-6644"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1321 NE 99TH AVE",
            "address_2": "SUITE 200",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972209436",
            "telephone_number": "503-216-8654",
            "fax_number": "503-216-8658"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "enumeration_date": "2006-10-17",
        "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 SECREATRY FOR ENROLLMENT",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "2086S0120X",
            "taxonomy_group": "",
            "desc": "Surgery, Pediatric Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PROVIDENCE PEDIATRIC SPECIALTIES III",
            "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.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.