Basic Information
| Provider Information | |||||||||
| NPI: | 1245544584 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE SPOKANE HEART INSTITUTE-MOSES LAKE PIONEER MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3776 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981243776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255256798 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1550 S PIONEER WAY | ||||||||
| Address2: | PIONEER MEDICAL CENTER #250 | ||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988374613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097667359 | ||||||||
| FaxNumber: | 5097642926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2010 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | DIR REIMB REG STRAT/ASST SEC ENROLL | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.