Basic Information
| Provider Information | |||||||||
| NPI: | 1184654139 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE PHYSICIAN GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 N BROADWAY | ||||||||
| Address2: | PBO/CREDENTIALING | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253170246 | ||||||||
| FaxNumber: | 4253170291 | ||||||||
| Practice Location | |||||||||
| Address1: | 4112 HARBOUR POINTE BLVD SW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MUKILTEO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982755457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253476330 | ||||||||
| FaxNumber: | 4253476335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 03/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | SCHUMACHER | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRO FEE CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4253476330 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7126964 | 05 | WA | MEDICAID |