1992083216 NPI number — PROVIDENCE PHYSICIAN SERVICES CO.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992083216 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:
1992083216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2011
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
820 S MCCLELLAN, SUITE 300
Provider Second Line Business Practice Location Address:
PROVIDENCE ORTHOPEDIC SPECIALTIES
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-464-7880
Provider Business Practice Location Address Fax Number:
509-464-7961
Provider Enumeration Date:
08/03/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MALLORY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
425-525-6798

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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