NPIMap

Organization Active NPI

Providence Health & Services - Oregon

Doing business as Providence Medical Group

  • Neurology Physician
  • Portland, OR
National Provider Identifier
1699804336
Registry record updated Jun 30, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Neurology PhysicianTaxonomy code 2084N0400X
Legal business name
PROVIDENCE HEALTH & SERVICES - OREGON
Doing business as
Providence Medical Group
Providence Neurological Specialties PSV MJP
Practice address
9427 SW Barnes Rd
Suite 595
Portland, OR 97225-6640
Phone
(503) 216-1150
Fax
(503) 216-1066
NPI assigned
Mar 5, 2007
Last updated
Jun 30, 2025By the provider in NPPES
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
Neurology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084N0400X Primary
Clinic/Center 261Q00000X

Addresses

Primary practice location

9427 SW Barnes Rd
Suite 595
Portland, OR 97225-6640

Mailing address

PO Box 31001 - 4180
Pasadena, CA 91110-4180

Other names 2

  • PROVIDENCE MEDICAL GROUP Doing business as
  • PROVIDENCE NEUROLOGICAL SPECIALTIES PSV 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

National Provider Directory

National Provider Directory

Locations

417 SW 117th Ave
Ste 100
Portland, OR 97225
Phone (503) 216-8980

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": "1173052800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751241600000",
    "number": "1699804336",
    "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": "9427 SW BARNES RD",
            "address_2": "SUITE 595",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972256640",
            "telephone_number": "503-216-1150",
            "fax_number": "503-216-1066"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-05",
        "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": "2084N0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PROVIDENCE NEUROLOGICAL SPECIALTIES PSV MJP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PROVIDENCE NEUROLOGICAL SPECIALTIES PSV 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 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.