1023385721 NPI number — PROVIDENCE PHYSICIAN SERVICES CO.

Table of content: (NPI 1023385721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023385721 NPI number — PROVIDENCE PHYSICIAN SERVICES CO.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE PHYSICIAN SERVICES CO.
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:
Provider Other Organization Name Type Code:
6
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:
1023385721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2011
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:
509-474-2072
Provider Business Mailing Address Fax Number:
509-474-6606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 W 8TH AVE
Provider Second Line Business Practice Location Address:
SUITE 7040
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99204-2302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-456-2406
Provider Business Practice Location Address Fax Number:
509-456-2407
Provider Enumeration Date:
11/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
KATLYN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CREDENTIALING & ONBOARDING SPECIALI
Authorized Official Telephone Number:
509-474-2072

Provider Taxonomy Codes

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

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





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