NPIMap

Organization Active NPI

Providence Health & Services Oregon

Doing business as Providence Seaside Hospital - Providence Cannon Beach Clinic

  • Rural Health Clinic/Center
  • Cannon Beach, OR
National Provider Identifier
1841756764
Registry record updated Apr 29, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PROVIDENCE HEALTH & SERVICES OREGON
Doing business as
Providence Seaside Hospital - Providence Cannon Beach Clinic
Providence Seaside Hospital, Providence Cannon Beach Clinic
Practice address
171 N Larch St Ste 16
Cannon Beach, OR 97110-3103
Phone
(503) 717-7400
NPI assigned
Feb 15, 2019
Last updated
Apr 29, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 29, 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 Enrollments
Phone
(425) 358-9786

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU
Multi-Specialty Clinic/Center 261QM1300X NU
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

171 N Larch St Ste 16
Cannon Beach, OR 97110-3103

Mailing address

PO Box 31001-4199
Pasadena, CA 91110-4199
Phone (503) 893-7120

Other names 2

  • PROVIDENCE SEASIDE HOSPITAL - PROVIDENCE CANNON BEACH CLINIC Doing business as
  • Providence Seaside Hospital, Providence Cannon Beach Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040102000768 OR Part B Supplier - Clinic/Group Practice 1557260106 Receives reassigned benefits from 319 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Cannon Beach, OR; Seaside, OR; Warrenton, OR
O20190607002251 OR Part A Provider - Rural Health Clinic 1557260106 Practice locations: Cannon Beach, OR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1841756764. Details of each certification follow.

Rural health clinic certification: CCN 388545

Legal name
PROVIDENCE HEALTH & SERVICES OREGON
Doing business as
PROVIDENCE SEASIDE HOSPITAL - PROVIDENCE CANNON BEACH CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 18, 2019
Last certification
Jul 23, 2019
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Feb 20, 1934 in OR
Enrollment address
171 N Larch St
Ste 16
Cannon Beach, OR 97110-3103
Related CCNs
381303

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
38D0939584Providence Cannon Beach Clinic171 Larch St, Cannon Beach, OR 97110Certificate of waiverDec 31, 2027

National Provider Directory

National Provider Directory
Tax ID family
Providence Health System3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Ownership & related parties

All disclosed owners & managing parties 26

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Diane L Hejna Individual Corporate DirectorDirector Jul 1, 2016
Richard S Blair Individual Corporate DirectorChairman, Board of Directors Jul 1, 2016
Providence Health & Services-Oregon Organization, Renton, WA Corporation, Non-profit 5% Or Greater Direct Ownership Interest May 14, 2010 100%
Marvin O'Quinn Individual Corporate DirectorBoard Member Jan 1, 2024
Linda Buck Individual Corporate DirectorBoard Member Jan 1, 2025
Providence Health & Services - Washington Organization, Renton, WA Non-profit, Chain home office Operational/Managerial Control May 14, 2010
Mary E Lyons Individual Corporate DirectorDirector Jul 1, 2016
Phyllis M Hughes Individual Corporate DirectorDirector Jan 1, 2014
Rogelio Riojas Individual Corporate DirectorBoard Member Jan 1, 2025
James Martin Individual Corporate Officer Jan 13, 2023
Charles Wallace Sorenson Individual Corporate DirectorDirector Jan 1, 2019
Pamela J Cooper Individual W-2 Managing EmployeeFinance Director Oct 1, 2000
Donald Wayne Anderson Individual Corporate OfficerAssistant Secretary of Enrollments Jan 1, 2017
Gregory David Hoffman Individual Corporate OfficerCfo/Treasurer Jan 1, 2023
Isiaah D Crawford Individual Corporate DirectorDirector Jan 1, 2012
Melissa Ann Damm Individual W-2 Managing EmployeeOregon Cfo Feb 19, 2019
Rebecca F Coplin Individual W-2 Managing EmployeeService Area Executive Jan 1, 2025
Donna Markham Individual Corporate DirectorBoard Member Jan 1, 2024
Michael W Murphy Individual Corporate DirectorBoard Member Jan 1, 2020
Providence Health & Services Organization, Renton, WA Non-profit Other Jul 1, 2016
Mary Beth Kingston Individual Corporate Director Sep 1, 2022
Eric D Sprunk Individual Corporate Director Jan 1, 2022
Anna R Newsom Individual Corporate Officer May 13, 2022
Darryl Elmouchi Individual Corporate OfficerPresident/Ceo Apr 1, 2025
Karin Dufault Individual Corporate DirectorBoard Member Jan 1, 2025
Providence St. Joseph Health Organization, Renton, WA Non-profit Other Jul 1, 2016

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 139

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 139

Practitioners & affiliated clinicians

Practitioners 26

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 26

NPI Registry JSON

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

{
    "created_epoch": "1550188800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1745884800000",
    "number": "1841756764",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 31001-4199",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911104199",
            "telephone_number": "503-893-7120",
            "fax_number": "425-276-3215"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "171 N LARCH ST STE 16",
            "city": "CANNON BEACH",
            "state": "OR",
            "postal_code": "971103103",
            "telephone_number": "503-717-7400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES OREGON",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-02-15",
        "last_updated": "2025-04-29",
        "certification_date": "2025-04-28",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE SEASIDE HOSPITAL - PROVIDENCE CANNON BEACH CLINIC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Seaside Hospital, Providence Cannon Beach Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Seaside Hospital, Providence Cannon Beach Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cannon Beach, OR

Sources for this page

Verify at the official NPI Registry.