PROVIDENCE HEALTH & SERVICES - OREGON (NPI# 1316024128) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1316024128 |
| Entity Type | Organization |
| Organization Name | PROVIDENCE HEALTH & SERVICES - OREGON |
| Other Organization Name | PMG SOUTH MEDFORD PEDIATRICS |
| Practice Address |
840 Royal Ave Suite 110 Medford OR 97504-6461 |
| Mailing Address |
Po Box 3158 Portland OR 97208-3158 |
| Practice Telephone | 5417328370 |
| Practice Fax Number | 5417328371 |
| Mailing Telephone | 5032156494 |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2020-01-15 |
| Authorized Official Name | JOHN W JACKSON (CHIEF EXECUTIVE OFFICER) |
| Authorized Official Telephone | 5417326000 |
| Authorized Official Credential | M.D. |
| Is Organization Subpart | Y |
| Parent Organization Name | PROVIDENCE HEALTH & SERVICES - OREGON |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 2084P0804X |
Psychiatry & Neurology Specialization: Child & Adolescent Psychiatry |
Allopathic & Osteopathic Physicians | ||
| N | 261QM0855X |
Clinic/Center Specialization: Adolescent and Children Mental Health |
Ambulatory Health Care Facilities | ||
| Y | 261Q00000X | Clinic/Center | Ambulatory Health Care Facilities |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| OR | RAIL ROAD MEDICARE | CG6801 | 01 |
| Other Name | Type Code |
|---|---|
| PMG SOUTH MEDFORD PEDIATRICS | Doing Business As Name - Organization |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1922481456 | Providence Health & Services - Oregon | Psychiatry & Neurology | 10830 Highway 62, Eagle Point, OR 97524-9516 | 2015-07-01 |
| 1023440435 | Providence Health & Services - Oregon | General Acute Care Hospital | 11445 Se Moon Dust Ct, Happy Valley, OR 97086-8033 | 2013-08-08 |
| 1568793313 | Providence Health & Services - Oregon | Clinic/Center | 17550 Provost St Ste 201, Lake Oswego, OR 97034-5199 | 2010-01-19 |
| 1508015348 | Providence Health & Services - Oregon | Clinic/Center | 16180 Se Sunnyside Road, Suite 102, Happy Valley, OR 97015-6302 | 2008-09-17 |
| 1114085545 | Providence Health & Services - Oregon | Internal Medicine | 1314 E Sherman St, Newberg, OR 97132-1842 | 2006-12-05 |
| 1629146121 | Providence Health & Services - Oregon | Otolaryngology | 310 Villa Rd, Suite 104, Newberg, OR 97132-1886 | 2006-12-01 |
| 1992882500 | Providence Health & Services - Oregon | Clinic/Center | 205 N Phoenix Rd, Suite A, Phoenix, OR 97535-9104 | 2006-11-01 |
| 1013018175 | Providence Health & Services - Oregon | Clinic/Center | 510 Bridge St, Vernonia, OR 97064-1218 | 2006-09-25 |
| 1447799523 | Providence Health & Services - Oregon | Clinic/Center | 1698 E Mcandrews Rd Ste 170, Medford, OR 97504-5590 | 2017-02-22 |
| 1063963106 | Providence Health & Services - Oregon | Clinic/Center | 1698 E Mcandrews Rd, Ste 300, Medford, OR 97504-5589 | 2016-10-24 |
| Entity Type | Entity Name | Entity Address |
|---|---|---|
| Colorado Business Entities | Providence Health & Services - Oregon | 1801 Lind Avenue, Sw, Renton, WA 98057-9016 |
| Oregon Corporations, Companies and Business Names | PROVIDENCE HEALTH & SERVICES - OREGON | 1801 Lind Ave Sw #9016, Renton, WA 98057 |
| System for Award Management (SAM) Entities | PROVIDENCE HEALTH & SERVICES - OREGON | 4400 Ne Halsey St Bldg 2 Ste 690, Portland, OR 97213-1545 |
| Iowa Business Entities | PROVIDENCE HEALTH & SERVICES - OREGON | 1801 Lind Ave. Sw, Renton, WA 98057 |
| Washington State Corporations | PROVIDENCE HEALTH & SERVICES - OREGON | 1801 Lind Ave Sw # 9016, Renton, WA 98057 |
| Street Address |
840 ROYAL AVE SUITE 110 |
| City | MEDFORD |
| State | OR |
| Zip Code | 97504-6461 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1629150420 | Michael A Davis | Pediatrics | 840 Royal Ave, Suite 110, Medford, OR 97504-6461 | 2006-10-20 |
| 1770033474 | Whitney A Serafini | Nurse Practitioner | 840 Royal Ave, Ste 110, Medford, OR 97504-6461 | 2016-10-06 |
| 1558693291 | Providence Health & Services - Oregon | Pharmacy | 840 Royal Ave, Suite 120, Medford, OR 97504-6461 | 2010-02-05 |
| 1972719268 | Amy J Munro | Pediatrics | 840 Royal Ave, Suite 110, Medford, OR 97504-6461 | 2007-05-15 |
| 1356400618 | Curtis T Oddo | Pediatrics | 840 Royal Ave, Suite 110, Medford, OR 97504-6461 | 2006-12-06 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1225673833 | Lydia D Sneed | Behavioral Analyst | 3707 Citation Way, Suite 102, Medford, OR 97504 | 2019-11-07 |
| 1114577368 | Heather Ashley Fronek | Nurse Practitioner | 2825 E. Barnett Rd., Medford, OR 97504 | 2019-09-18 |
| 1255809109 | Justin Blasdel | Technician, Health Information | 3250 Lone Pine Rd, Medford, OR 97504 | 2018-11-08 |
| 1396220133 | Aimee K Michel | Massage Therapist | 3550 National Dr., Medford, OR 97504 | 2018-09-27 |
| 1437646908 | Zola Dental Medford LLC | Dentist | 922 E Main, Medford, OR 97504 | 2018-04-19 |
| 1376068015 | Megan Leggett | Counselor | 777 Murphy Road, Medford, OR 97504 | 2017-08-03 |
| 1023547536 | Joshua Morgan Rice | Dentist | 1117 E Main St Ste 1, Medford, OR 97504 | 2017-06-08 |
| 1427580232 | Paul James Dean | Counselor | 1175 Main St Ste 1c, Medford, OR 97504 | 2017-03-30 |
| 1811443542 | Taya Adams | Doula | 1201 Progress Dr #90, Medford, OR 97504 | 2016-09-01 |
| 1174076228 | Avalon Health Care - Hearthstone, LLC | Skilled Nursing Facility | 2091 E. Barnett Road, Medford, OR 97504 | 2016-07-25 |
| Find all providers in zip 97504 | ||||
| Taxonomy Code | 261Q00000X |
| Grouping | Ambulatory Health Care Facilities |
| Classification | Clinic/Center |
| A facility or distinct part of one used for the diagnosis and treatment of outpatients. "Clinic/Center" is irregularly defined, sometimes being limited to organizations serving specialized treatment requirements or distinct patient/client groups (e.g., radiology, poor, and public health). |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1275157000 | Provident Health Partners Inc. | Clinic/Center | 1529 N Ocean Ave Ste A, Medford, NY 11763-3587 | 2020-06-08 |
| 1427680057 | Ortc, LLC | Clinic/Center | 750 Biddle Rd Ste 102, Medford, OR 97504-6178 | 2020-02-11 |
| 1528543949 | Planned Parenthood of Southwestern Oregon | Clinic/Center | 125 S Central Ave Ste 201, Medford, OR 97501-7222 | 2018-10-02 |
| 1417438359 | Ideal Option, Pllc | Clinic/Center | 216 E Main St Ste 201, Medford, OR 97501-6029 | 2018-08-28 |
| 1750828778 | Regis College | Clinic/Center | 50 Dexter St, 1, Medford, MA 02155-6668 | 2017-01-28 |
| 1629428248 | Southern Oregon Denture & Dental | Clinic/Center | 41 Hawthorne St, Medford, OR 97504-7113 | 2016-06-14 |
| 1881021715 | Oregon Health Sciences University | Clinic/Center | 3192 Arnold Palmer Way, Medford, OR 97504-7773 | 2013-10-10 |
| 1023372067 | Riverside Chiropractic Wellness Centers, Inc | Clinic/Center | 65 Riverside Ave Ste C, Medford, MA 02155-4653 | 2012-06-25 |
| 1497051320 | Northwest Diagnostic Services | Clinic/Center | 2728 W Main St, Suite 121, Medford, OR 97501-2499 | 2011-02-10 |
| 1265745541 | Oregon Internal Medicine, LLC. | Clinic/Center | 2380 W Main St, Suite, A, Medford, OR 97501-2390 | 2010-07-15 |
| Find all providers in MEDFORD | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.