Basic Information
| Provider Information | |||||||||
| NPI: | 1124163118 | ||||||||
| 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 196276 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995196276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075656522 | ||||||||
| FaxNumber: | 9075656593 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 PROVIDENCE DR | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075656522 | ||||||||
| FaxNumber: | 9075656593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 12/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | PARRISH | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9072613082 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE ALASKA MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | NOT NUMBERED | AK | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.