1538311287 NPI number — PROVIDENCE HEALTH & SERVICES-WA

Table of content: (NPI 1538311287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538311287 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:
NW HEART & LUNG SURGICAL ASSOC
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:
1538311287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 312
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:
99019-3012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-456-0262
Provider Business Mailing Address Fax Number:
425-276-3215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
62 W 7TH AVE STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99204-2321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-456-0262
Provider Business Practice Location Address Fax Number:
509-462-5059
Provider Enumeration Date:
10/14/2008

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 ENROLLMT/DIR REIMB REG
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  600503828 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G8878011 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8878024 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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