Providence Health & Services - Oregon

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

PROVIDENCE HEALTH & SERVICES - OREGON

Doing business as

Providence Medical Group
Providence Medical Group Glisan Dermatology at Sunnyside

Practice address

9290 SE Sunnybrook Blvd
Suite 120
Clackamas, OR 97015-6802

Phone

(503) 215-9080

Fax

(503) 215-9099

NPI assigned

Jan 6, 2014

Organization subpart

No

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

Authorized official

Name

Donald Wayne Anderson Jr.

Title

Asst Sec Enrollment

Phone

(425) 358-9786

Specialties & licenses 2

Addresses

Other names 2

• PROVIDENCE MEDICAL GROUP Doing business as
• Providence Medical Group Glisan Dermatology at Sunnyside Doing business as

Medicare fee-for-service enrollment

Enrolled in OR

Enrollment records 1

Practitioners 3

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

• Nicole Benthin, NP

  • Family Nurse Practitioner
  • Seaside, OR
  • NPI 1407400500
  NPD
• Rebecca S Lee, FNP

  • Family Nurse Practitioner
  • Portland, OR
  • NPI 1669198446
  NPD
• Shai D Rosenfeld, MD

  • Family Medicine Physician
  • Portland, OR
  • NPI 1386904837
  NPD

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

{
    "created_epoch": "1388966400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751328000000",
    "number": "1790107050",
    "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": "9290 SE SUNNYBROOK BLVD",
            "address_2": "SUITE 120",
            "city": "CLACKAMAS",
            "state": "OR",
            "postal_code": "970156802",
            "telephone_number": "503-215-9080",
            "fax_number": "503-215-9099"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-01-06",
        "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": "WAYNE",
        "authorized_official_title_or_position": "ASST SEC 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": "PROVIDENCE MEDICAL GROUP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Medical Group Glisan Dermatology at Sunnyside",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Myles Prince, RN
• Kelly A Probst, DO
• Mark M Prochnau, MSN, CRNA
• Stephen Proctor
• Proventus Psychiatry
• Providence Health & Services Oregon (Providence Medical Group)
• Providence Health & Services Oregon (Prov Health Sys-OR Shared-Svs Div)
• Bret A. Provost, O.D.
• Psychological Solutions Inc.
• Hannah Elizabeth Pugh, PHARM.D.

• Dermatology Physician in Clackamas, OR
• Providers in Clackamas, OR by specialty
• Dermatology Physician in Oregon

• 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.
• 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.