1033309604 NPI number — PROVIDENCE HEALTH & SERVICES WASHINGTON

Table of content: (NPI 1033309604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033309604 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 INTERNAL MEDI
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:
1033309604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 34439
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-1439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-525-6778
Provider Business Mailing Address Fax Number:
425-525-6700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 NORTHWEST LANE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98503-6908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-491-4460
Provider Business Practice Location Address Fax Number:
360-491-3090
Provider Enumeration Date:
07/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
QUINN
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
PAYOR CREDENTIALING MANAGER
Authorized Official Telephone Number:
425-525-6715

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 8944993 . This is a "L&I CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 342006812 . This is a "MASTER LICENSE WASHINGTON" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7138694 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 223577 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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