1922259738 NPI number — PROVIDENCE HEALTH & SERVICES - WASHINGTON

Table of content: (NPI 1922259738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922259738 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 MEDICAL GROUP SOUTHEAST WASHINGTON
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:
1922259738
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 32
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTY LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99019-0032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-529-8905
Provider Business Mailing Address Fax Number:
509-526-8402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
380 CHASE AVENUE
Provider Second Line Business Practice Location Address:
PMG SE WA
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-2924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-526-3333
Provider Business Practice Location Address Fax Number:
509-526-8402
Provider Enumeration Date:
10/10/2008

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 OF ENROLLMENT/DIR REIMB ST
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: H-050 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: H-050 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: H-050 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: H-050 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 115284 . This is a "L&I STATE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7028186 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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