Basic Information
| Provider Information | |||||||||
| NPI: | 1093720534 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES - WASHINGTON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE MATANUSKA HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2250 S. WOODWORTH LOOP | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PALMER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077615900 | ||||||||
| FaxNumber: | 9077615975 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 S. WOODWORTH LOOP | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PALMER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077615900 | ||||||||
| FaxNumber: | 9077615975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | PALMER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9077615916 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HEALTH AND SERVICES ALASKA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MDG669 | 05 | AK | MEDICAID |