Providence Health & Services - Oregon
Organization Active NPI Family Medicine Physician · Eagle Point, OR
NPI 1992031595 · NPPES record last updated Nov 19, 2025
Key facts
- NPI
- 1992031595
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- PROVIDENCE HEALTH & SERVICES - OREGON
- Practice address
- 1332 S Shasta Ave
Suite a
Eagle Point, OR 97524-8623 - Phone
- (541) 826-8160
- Fax
- (541) 826-8197
- NPI assigned
- Nov 2, 2009
- Organization subpart
- Yes
- Parent organization (as reported)
- PROVIDENCE HEALTH & SERVICES - OREGON
Authorized official
- Name
- Donald Wayne Anderson Jr.
- Title
- Assistant Secretary Enrollment
- Phone
- (425) 358-9786
Other NPIs on the same Medicare enrollment 25
Corporate family (same tax ID) 5
Practitioners 9
-
Julian W Bell, MD
-
Kenneth Allan Jacobs, M.D.
-
Richard Lloyd Julyan, M.D.
-
Stefanie T Ogawa, M.D.
-
Wesley T Ramoso, MD
-
Michael J Trinkler, PA-C
-
Michael A Wilson, MD
-
Andre' Tyrone Bobo, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 38D0876975 | PMG Eagle Point | Certificate of waiver | Apr 30, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OR
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040310000315 | OR | Part B Supplier - Clinic/Group Practice | 5294623245 |
Receives reassigned benefits from 200 practitioners 25 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Central Point, OR; Medford, OR; Grants Pass, OR; Eagle Point, OR |
National Provider Directory
- Tax ID family
- Providence Health Services
- Part of
- Providence Health Services
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes | ||
| Pediatrics Physician |
208000000X | |||
| Child & Adolescent Psychiatry Physician |
2084P0804X | |||
| Geriatric Psychiatry Physician |
2084P0805X | |||
| Multi-Specialty Clinic/Center | 261QM1300X |
Addresses
Primary practice location
1332 S Shasta Ave
Suite a
Eagle Point, OR 97524-8623
Mailing address
PO Box 31001 - 4180
Pasadena, CA 91110-4180
Phone (541) 826-8160
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 500617058 | Medicaid | OR |
Other names
- PMG SOUTH EAGLE POINT
- PROVIDENCE MEDICAL GROUP SOUTH
Other providers in Eagle Point, OR
- Megan Peters
- Alexander Gregory O'Neal Petersen
- Austen Cimone Petersen
- Kasandra K Prill
- Providence Health & Services - Oregon
- Robert L Nutting
- Wendy Robinson
- Rogue Community Health
- Rogue Community Health
- Rogue Community Health
All providers in Eagle Point, OR · Family Medicine Physician in Oregon
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 19, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.