1093720534 NPI number — PROVIDENCE HEALTH & SERVICES - WASHINGTON

Table of content: (NPI 1093720534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093720534 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:
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:
1093720534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2250 S. WOODWORTH LOOP
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
PALMER
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-761-5900
Provider Business Mailing Address Fax Number:
907-761-5975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2250 S. WOODWORTH LOOP
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PALMER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-761-5900
Provider Business Practice Location Address Fax Number:
907-761-5975
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PALMER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
CLINIC ADMINISTRATOR
Authorized Official Telephone Number:
907-761-5916

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MDG669 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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