NPIMap

Organization Active NPI

Providence Health & Services - Oregon

  • Dermatology Physician
  • Tigard, OR
National Provider Identifier
1770723017
Registry record updated Jul 1, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
PROVIDENCE HEALTH & SERVICES - OREGON
Practice address
18040 SW Lower Boones Ferry Rd
Suite 100
Tigard, OR 97224-7215
Phone
(503) 216-0700
NPI assigned
Feb 26, 2009
Organization subpart
Yes
Parent organization
PROVIDENCE HEALTH & SERVICES - OREGONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 1, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Donald W Anderson Jr.
Title
Assistant Secretary Enrollment
Phone
(425) 358-9786

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207N00000X Primary
Clinic/Center 261Q00000X

Addresses

Primary practice location

18040 SW Lower Boones Ferry Rd
Suite 100
Tigard, OR 97224-7215

Mailing address

PO Box 31001 - 4180
Pasadena, CA 91110-4180

Other names 2

  • PMG BRIDGEPORT DERMATOLOGY Doing business as
  • PROVIDENCE MEDICAL GROUP Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Scholls Medical Group45 organizations share this tax ID, including this one
Part of
Scholls 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": "1235606400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751328000000",
    "number": "1770723017",
    "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": "18040 SW LOWER BOONES FERRY RD",
            "address_2": "SUITE 100",
            "city": "TIGARD",
            "state": "OR",
            "postal_code": "972247215",
            "telephone_number": "503-216-0700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "enumeration_date": "2009-02-26",
        "last_updated": "2025-07-01",
        "certification_date": "2025-07-01",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY ENROLLMENT",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "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": "PMG BRIDGEPORT DERMATOLOGY",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tigard, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 1, 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.