1194930313 NPI number — PROVIDENCE HEALTH & SERVICES WASHINGTON

Table of content: (NPI 1194930313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194930313 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:
1194930313
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:
8645 MARTIN WAY E
Provider Second Line Business Practice Location Address:
BLDG 2
Provider Business Practice Location Address City Name:
LACEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98516-5800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-923-4600
Provider Business Practice Location Address Fax Number:
360-923-4663
Provider Enumeration Date:
05/11/2007

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: 207R00000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RE0101X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 600 672 503 . This is a "TAX REGSTRATION NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8943381 . This is a "L&I CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 342 006 812 . This is a "UNIFIED BUSINESS ID #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 215633 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7129661 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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