| Providence Medical Group | |
|
12442 Sw Scholls Ferry Rd Suite 100 Tigard OR 97223-0803 | |
| (503) 216-9900 | |
| (503) 216-9266 |
| Full Name | Providence Medical Group |
|---|---|
| Speciality | Family Medicine |
| Location | 12442 Sw Scholls Ferry Rd, Tigard, Oregon |
| Authorized Official Name and Position | Donald Wayne Anderson (ASSISTANT SECRETARY ENROLLMENT) |
| 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 12442 Sw Scholls Ferry Rd Suite 100 Tigard OR 97223-0803 Ph: (503) 216-9900 |
| NPI Number | 1396836276 |
|---|---|
| Provider Enumeration Date | 09/27/2006 |
| Last Update Date | 07/11/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1396836276 | NPI | - | NPPES |
| 063680 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 261Q00000X | Clinic/center | (* (Not Available)) | Secondary |
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