NPIMap

Organization Active NPI

Providence Health & Services - Oregon

Doing business as Providence Medical Group South

  • Nurse Practitioner
  • Portalnd, OR
National Provider Identifier
1790113405
Registry record updated Mar 25, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
Legal business name
PROVIDENCE HEALTH & SERVICES - OREGON
Doing business as
Providence Medical Group South
Providence Health eXpress BP
Practice address
4400 NE Halsey
BLDG 2 3Rd FLR
Portalnd, OR 97213
Phone
(855) 229-6460
Fax
(503) 216-0710
NPI assigned
Oct 16, 2013
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 25, 2026

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
Clinic/Center 261Q00000X
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X Primary

Addresses

Primary practice location

4400 NE Halsey
BLDG 2 3Rd FLR
Portalnd, OR 97213

Mailing address

PO Box 3158
Portland, OR 97208-3158

Other names 2

  • PROVIDENCE MEDICAL GROUP SOUTH Doing business as
  • Providence Health eXpress BP 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

4400 NE Halsey St
#2
Portland, OR 97213
Phone (503) 893-6472

18040 SW Lower Boones Ferry Rd
Ste 100
Tigard, OR 97224
Phone (503) 216-0624

Practitioners & affiliated clinicians

Practitioners 12

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

NPI Registry JSON

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

{
    "created_epoch": "1381881600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1774396800000",
    "number": "1790113405",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3158",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083158"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4400 NE HALSEY",
            "address_2": "BLDG 2 3RD FLR",
            "city": "PORTALND",
            "state": "OR",
            "postal_code": "97213",
            "telephone_number": "855-229-6460",
            "fax_number": "503-216-0710"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-10-16",
        "last_updated": "2026-03-25",
        "certification_date": "2026-03-25",
        "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": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP SOUTH",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Health eXpress BP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Health eXpress BP",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2026; 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.