| Providence Medical Group | |
|
5211 Ne Glisan St Bldg C Portland OR 97213-3052 | |
| (503) 215-6628 | |
| (503) 215-6240 |
| Full Name | Providence Medical Group |
|---|---|
| Speciality | Clinic/Center |
| Location | 5211 Ne Glisan St Bldg C, Portland, Oregon |
| Authorized Official Name and Position | Donald Wayne Anderson (ASST SECRETARY ENROLLMENT) |
| 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 5211 Ne Glisan St Bldg C Portland OR 97213-3052 Ph: (503) 215-6628 | Providence Medical Group 5211 Ne Glisan St Bldg C Portland OR 97213-3052 Ph: (503) 215-6628 |
| NPI Number | 1003319724 |
|---|---|
| Provider Enumeration Date | 03/09/2018 |
| Last Update Date | 03/09/2018 |
| Medicare PECOS PAC ID | 0648183608 |
|---|---|
| Medicare Enrollment ID | O20180621000031 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1003319724 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
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