| Providence Medical Group | |
|
5050 Ne Hoyt St Ste 315 Portland OR 97213-2982 | |
| (503) 215-8580 | |
| (971) 282-0125 |
| Full Name | Providence Medical Group |
|---|---|
| Speciality | Psychiatry & Neurology - Neurology |
| Location | 5050 Ne Hoyt St Ste 315, Portland, Oregon |
| Authorized Official Name and Position | Donald Wayne Anderson (ASSISTANT SECRETARY ENROLLMENTS) |
| Authorized Official Contact | 4255255392 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Medical Group Po Box 3158 Portland OR 97208-3158 Ph: () - | Providence Medical Group 5050 Ne Hoyt St Ste 315 Portland OR 97213-2982 Ph: (503) 215-8580 |
| NPI Number | 1578807418 |
|---|---|
| Provider Enumeration Date | 11/15/2012 |
| Last Update Date | 10/01/2024 |
| Certification Date | 10/01/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1578807418 | NPI | - | NPPES |
| 500653793 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084N0400X | Psychiatry & Neurology - Neurology | (* (Not Available)) | Primary |
| 261Q00000X | Clinic/center | (* (Not Available)) | Secondary |
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