| Providence Medical Group | |
|
5050 Ne Hoyt St Suite 240 Portland OR 97213-2981 | |
| (503) 215-6480 | |
| (503) 215-6469 |
| Full Name | Providence Medical Group |
|---|---|
| Speciality | Family Medicine |
| Location | 5050 Ne Hoyt St, 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: (503) 215-6494 | Providence Medical Group 5050 Ne Hoyt St Suite 240 Portland OR 97213-2981 Ph: (503) 215-6480 |
| NPI Number | 1790880805 |
|---|---|
| Provider Enumeration Date | 09/13/2006 |
| Last Update Date | 09/10/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1790880805 | NPI | - | NPPES |
| 052394 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 261Q00000X | Clinic/center | (* (Not Available)) | Secondary |
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