Basic Information
Provider Information | |||||||||
NPI: | 1073744850 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROVIDENCE HEALTH & SERVICES WASHINGTON | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROVIDENCE ST PETER HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 34439 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981241439 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4255256778 | ||||||||
FaxNumber: | 4255256700 | ||||||||
Practice Location | |||||||||
Address1: | 2505 OLYMPIC HWY N. | ||||||||
Address2: | STE 140 | ||||||||
City: | SHELTON | ||||||||
State: | WA | ||||||||
PostalCode: | 985842978 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604328692 | ||||||||
FaxNumber: | 3604329902 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2009 | ||||||||
LastUpdateDate: | 12/22/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | QUINN | ||||||||
AuthorizedOfficialFirstName: | NICOLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PAYOR CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4255256715 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X |   |   | N |   | Hospital Units | Rehabilitation, Substance Use Disorder Unit |   | 261QR0405X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
ID | Type | State | Issuer | Description | 1993062 | 05 | WA |   | MEDICAID |