| Providence Medical Group | |
|
440 Nw Division St Gresham OR 97030-5506 | |
| (503) 215-9500 | |
| (503) 215-9525 |
| Full Name | Providence Medical Group |
|---|---|
| Speciality | Clinic/center |
| Location | 440 Nw Division St, Gresham, Oregon |
| Authorized Official Name and Position | Donald W Anderson (DIR REIMB REG STRAT/ASST SEC ENROLL) |
| 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 440 Nw Division St Gresham OR 97030-5506 Ph: (503) 215-9500 |
| NPI Number | 1053419218 |
|---|---|
| Provider Enumeration Date | 09/20/2006 |
| Last Update Date | 08/31/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053419218 | NPI | - | NPPES |
| 287333 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207RE0101X | Internal Medicine - Endocrinology, Diabetes & Metabolism | (* (Not Available)) | Secondary |
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
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