Basic Information
| Provider Information | |||||||||
| NPI: | 1053363119 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES WASHINGTON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE ALASKA MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4048 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075656522 | ||||||||
| FaxNumber: | 9075656592 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 PROVIDENCE DR | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075656522 | ||||||||
| FaxNumber: | 9075656592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY FOR ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | NOT NUMBERED | AK | Y | Hospitals | General Acute Care Hospital |
No ID Information.