Basic Information
| Provider Information | |||||||||
| NPI: | 1194930313 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH & SERVICES WASHINGTON | ||||||||
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| OtherOrganizationName: | PROVIDENCE ST PETER INTERNAL MEDI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34439 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255256778 | ||||||||
| FaxNumber: | 4255256700 | ||||||||
| Practice Location | |||||||||
| Address1: | 8645 MARTIN WAY E | ||||||||
| Address2: | BLDG 2 | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985165800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609234600 | ||||||||
| FaxNumber: | 3609234663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 12/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | QUINN | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PAYOR CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4255256715 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207R00000X | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 600 672 503 | 01 | WA | TAX REGSTRATION NUMBER | OTHER | 8943381 | 01 | WA | L&I CRIME VICTIMS | OTHER | 342 006 812 | 01 | WA | UNIFIED BUSINESS ID # | OTHER | 215633 | 01 | WA | L&I | OTHER | 7129661 | 05 | WA | MEDICAID |