Active NPI
Robert Provenzano, MD
- Nephrology Physician
- Portland, OR
National Provider Identifier
1972505584
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Nephrology Physician
- License
- RP047354
- Practice address
- 1547 NE 40TH Ave Ste B
Portland, OR 97232-1862 - Phone
- (855) 397-0197
- NPI assigned
- Aug 12, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 11
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nephrology Physician | 207RN0300X | M-11205 | ID | |
| Nephrology Physician | 207RN0300X | 4301047354 | MI | |
| Nephrology Physician | 207RN0300X | 54729 | AZ | |
| Nephrology Physician | 207RN0300X | 2017-00405 | NC | |
| Nephrology Physician | 207RN0300X | 40429 | SC | |
| Nephrology Physician | 207RN0300X | MD463387 | PA | |
| Nephrology Physician | 207RN0300X | ME118456 | FL | |
| Nephrology Physician | 207RN0300X | 48234 | CO | |
| Nephrology Physician | 207RN0300X | MD0000053388 | TN | |
| Nephrology Physician | 207RN0300X | MD170613 | OR | |
| Nephrology Physician | 207RN0300X | RP047354 | MI | Primary |
Addresses
Primary practice location
1547 NE 40TH Ave Ste B
Portland, OR 97232-1862
Mailing address
1840 E Ray Rd
Chandler, AZ 85225-8720
Phone (855) 397-0197
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 54729 | AZ | MD | Nephrology Physician |
| ME118456 | FL | MD | Nephrology Physician |
| 4301047354 | MI | MD | Nephrology Physician |
| RP047354 | MI | MD | Nephrology Physician |
| 2017-00405 | NC | MD | Nephrology Physician |
| MD170613 | OR | MD | Nephrology Physician |
| MD463387 | PA | MD | Nephrology Physician |
| 40429 | SC | MD | Nephrology Physician |
| MD0000053388 | TN | MD | Nephrology Physician |
| 48234 | CO | MD | Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| NPS Physicians Pittsburgh, LLC | Nephrology | Current | Accepting new patients |
| NPS Physicians TN PLLC | Nephrology | Current | Accepting new patients |
| Kidney Care Centers | Nephrology | Current | Accepting new patients |
Locations
1840 E Ray Rd
Chandler, AZ 85225
Phone (855) 397-0197
Interoperability endpoints
- https://fhir.fhirpoint.open.allscripts.com/fhirroute/open/72674
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1123804800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1574726400000",
"number": "1972505584",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1840 E RAY RD",
"city": "CHANDLER",
"state": "AZ",
"postal_code": "852258720",
"telephone_number": "855-397-0197",
"fax_number": "800-272-6512"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1547 NE 40TH AVE STE B",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972321862",
"telephone_number": "855-397-0197"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PROVENZANO",
"first_name": "ROBERT",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-08-12",
"last_updated": "2019-11-26",
"status": "A"
},
"taxonomies": [
{
"code": "207RN0300X",
"taxonomy_group": "",
"desc": "Internal Medicine, Nephrology",
"state": "ID",
"license": "M-11205",
"primary": false
},
{
"code": "207RN0300X",
"taxonomy_group": "",
"desc": "Internal Medicine, Nephrology",
"state": "MI",
"license": "4301047354",
"primary": false
},
{
"code": "207RN0300X",
"taxonomy_group": "",
"desc": "Internal Medicine, Nephrology",
"state": "AZ",
"license": "54729",
"primary": false
},
{
"code": "207RN0300X",
"taxonomy_group": "",
"desc": "Internal Medicine, Nephrology",
"state": "NC",
"license": "2017-00405",
"primary": false
},
{
"code": "207RN0300X",
"taxonomy_group": "",
"desc": "Internal Medicine, Nephrology",
"state": "SC",
"license": "40429",
"primary": false
},
{
"code": "207RN0300X",
"taxonomy_group": "",
"desc": "Internal Medicine, Nephrology",
"state": "PA",
"license": "MD463387",
"primary": false
},
{
"code": "207RN0300X",
"taxonomy_group": "",
"desc": "Internal Medicine, Nephrology",
"state": "FL",
"license": "ME118456",
"primary": false
},
{
"code": "207RN0300X",
"taxonomy_group": "",
"desc": "Internal Medicine, Nephrology",
"state": "CO",
"license": "48234",
"primary": false
},
{
"code": "207RN0300X",
"taxonomy_group": "",
"desc": "Internal Medicine, Nephrology",
"state": "TN",
"license": "MD0000053388",
"primary": false
},
{
"code": "207RN0300X",
"taxonomy_group": "",
"desc": "Internal Medicine, Nephrology",
"state": "OR",
"license": "MD170613",
"primary": false
},
{
"code": "207RN0300X",
"taxonomy_group": "",
"desc": "Internal Medicine, Nephrology",
"state": "MI",
"license": "RP047354",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}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 Nov 26, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.