1033398763 NPI number — PROVIDENCE HEALTH & SERVICES WASHINGTON

Table of content: (NPI 1033398763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033398763 NPI number — PROVIDENCE HEALTH & SERVICES WASHINGTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH & SERVICES WASHINGTON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROVIDENCE ST PETER HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033398763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3505
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-525-6717
Provider Business Mailing Address Fax Number:
425-525-6700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 LILLY RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506-5133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-491-9480
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
DIRECTOR REIMBURSEMENT ADMINISTRATI
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7135932 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8901337 . This is a "L&I CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 129210 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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