| Providence Medical Group | |
|
4400 Ne Halsey St Portland OR 97213-1545 | |
| (503) 893-6524 | |
| Not Available |
| Full Name | Providence Medical Group |
|---|---|
| Speciality | Clinic/Center |
| Location | 4400 Ne Halsey St, Portland, Oregon |
| Authorized Official Name and Position | Donald Wayne Anderson (ASST CORP SEC FOR ENROLLMENTS) |
| Authorized Official Contact | 4255255392 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Medical Group Po Box 3158 Portland OR 97208-3158 Ph: () - | Providence Medical Group 4400 Ne Halsey St Portland OR 97213-1545 Ph: (503) 893-6524 |
| NPI Number | 1164623401 |
|---|---|
| Provider Enumeration Date | 05/31/2007 |
| Last Update Date | 10/14/2022 |
| Certification Date | 10/14/2022 |
| Medicare PECOS PAC ID | 0648183608 |
|---|---|
| Medicare Enrollment ID | O20181217001928 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1164623401 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 104100000X | Social Worker | (* (Not Available)) | Secondary |
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
| Provider Name | Joshua Jones |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1548361009 PECOS PAC ID: 5395844591 Enrollment ID: I20240126003056 |
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