1093956278 NPI number — PROVIDENCE HEALTH & SERVICES- WASHINGTON

Table of content: (NPI 1093956278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093956278 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:
1093956278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2024
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:
3200 PROVIDENCE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508-4615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-212-6002
Provider Business Practice Location Address Fax Number:
907-212-8340
Provider Enumeration Date:
03/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
W
Authorized Official Title or Position:
ASST SEC ENROLLMT/DIR REIMB ADMIN
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1020543 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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