Basic Information
| Provider Information | |||||||||
| NPI: | 1033309604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES WASHINGTON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE ST PETER INTERNAL MEDI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34439 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255256778 | ||||||||
| FaxNumber: | 4255256700 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 NORTHWEST LANE SE | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985036908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604914460 | ||||||||
| FaxNumber: | 3604913090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2007 | ||||||||
| LastUpdateDate: | 12/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | QUINN | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PAYOR CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4255256715 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207QG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8944993 | 01 | WA | L&I CRIME VICTIMS | OTHER | 342006812 | 01 | WA | MASTER LICENSE WASHINGTON | OTHER | 7138694 | 05 | WA | MEDICAID | 223577 | 01 | WA | L&I | OTHER |