1437300829 NPI number — PROVIDENCE HEALTH & SERVICES - WA

Table of content: (NPI 1437300829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437300829 NPI number — PROVIDENCE HEALTH & SERVICES - WA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH & SERVICES - WA
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:
PMG NW WA MC PEDIATRICS
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:
1437300829
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3360
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:
97208-3360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-399-2983
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12800 BOTHELL EVERETT HWY
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98208-6644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-316-5160
Provider Business Practice Location Address Fax Number:
425-225-1005
Provider Enumeration Date:
10/04/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
ASST SEC FOR ENROLLMENT/DIR REIMB S
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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