1538254347 NPI number — PROVIDENCE HEALTH & SERVICES WASHINGTON

Table of content: (NPI 1538254347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538254347 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 ALASKA
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:
1538254347
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4105
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:
97208-4105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-907-1068
Provider Business Mailing Address Fax Number:
425-917-9141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3760 PIPER ST
Provider Second Line Business Practice Location Address:
SUITE 1108
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508-4683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-212-6900
Provider Business Practice Location Address Fax Number:
907-212-6936
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
W
Authorized Official Title or Position:
ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  282054 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1020510 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1029396 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1595841 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1595851 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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