| Providence Medical Group | |
|
440 Nw Division St Gresham OR 97030-5506 | |
| (503) 962-1000 | |
| (503) 963-3005 |
| Full Name | Providence Medical Group |
|---|---|
| Speciality | Internal Medicine - Cardiovascular Disease |
| Location | 440 Nw Division St, Gresham, Oregon |
| Authorized Official Name and Position | Donald W Anderson (ASSISTANT SECRETARY ENROLLMENT) |
| Authorized Official Contact | 4253589786 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Medical Group Po Box 31001 - 4180 Pasadena CA 91110-4180 | Providence Medical Group 440 Nw Division St Gresham OR 97030-5506 Ph: (503) 962-1000 |
| NPI Number | 1437442795 |
|---|---|
| Provider Enumeration Date | 05/19/2011 |
| Last Update Date | 07/04/2025 |
| Certification Date | 07/04/2025 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1437442795 | NPI | - | NPPES |
| 500639264 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | () | Secondary |
| 207RC0000X | Internal Medicine - Cardiovascular Disease | () | Primary |
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