1215225099 NPI number — PROVIDENCE HEALTH & SERVICES-WA

Table of content: (NPI 1215225099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215225099 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:
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:
1215225099
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2012
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:
425-316-5439
Provider Business Mailing Address Fax Number:
425-316-5484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14692 179TH AVE SE
Provider Second Line Business Practice Location Address:
STE 800
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98272-1162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-794-7994
Provider Business Practice Location Address Fax Number:
360-805-4786
Provider Enumeration Date:
07/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
NICOL
Authorized Official First Name:
MARCY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR RCM NWR PHYSICIAN DIVISION
Authorized Official Telephone Number:
425-317-0284

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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